Please respond to the following discussion posts Samantha’s discussion prompt 4.

Please respond to the following discussion posts
Samantha’s discussion prompt 4.1
The Quality and Safety Education for Nurses (QSEN) exists so that it may be used as the foundation for ensuring that today’s nursing workforce is equipped to address quality and safety factors (Yoder-Wise & Sportsman, 2023). QSEN is comprised of six competencies: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. In my practice, teamwork and collaboration are a must in order to ensure that the patient remains safe throughout the duration of their surgical experience. The surgical team typically consists of the surgeon, physician assistant, surgical technologist, circulator, certified registered nurse anesthetist (CRNA), anesthesiologist, and pre-operative nurse, to name a few. Each of these team members play a unique role in the patient’s care to include prior, during and after surgery. One of many great things about the operating room is that there is only one patient being cared for at a time by this team. Prior to incision or the official start of the surgery, a surgical timeout is performed. The timeout is part of the Universal Protocol created by the Joint Commission to prevent wrong site, wrong patient, and wrong procedure events from occurring. It is an opportunity prior to surgery for all members of the care team to stop what they are doing, listen to the timeout, and ensure that if there are any safety concerns that they will speak up and prevent potential harm from occurring to the patient (Kooiker, 2024). Timeouts are a standard practice of care that has been implemented in nursing practice to lessen the chance of a preventable sentinel event from occurring. A key organization within the operating room specialty that is leading patient safety movements in the U.S. is the Association of periOperative Room Nurses (AORN). This organization advocates for and supports operating room nurses with evidence-based practice, up-to-date research, and continued education so that surgical nurses across the nation are equipped to provide the safest possible care for their patients.
Amy’s discussion Prompt #4.2
In my practice, two errors stand out, one resulting in harm to the patient and the other avoided through timely intervention.
The first error occurred when a night nurse at my facility failed to offer a crib to a mother and infant patient in the emergency department (ED). The mother and infant were placed on a stretcher, and as a result, the infant rolled off and sustained minor injuries. This incident highlighted a serious breach in patient safety protocols. In response, the team held multiple nursing huddles to discuss the importance of offering the ED crib to all infant patients. The huddles emphasized that proper documentation must reflect that the crib was offered and, if refused, that the parent was educated on the safety risks. This incident aligns with the broader principle of patient safety as outlined by Yoder-Wise & Sportsman (2022), who emphasize that nurses must challenge unsafe practices and ensure that patient safety is always prioritized (p. 45).
The second error, which did not result in harm, involved a medication order entered by a doctor I was working with. The order was verified by pharmacy, but it was mistakenly placed in the wrong patient’s chart. I noticed that the patient had not yet been seen by the doctor, so I politely confronted them. Together, we identified the error and corrected it before any harm occurred. This proactive approach in preventing errors is necessary, as emphasized by Yoder-Wise & Sportsman (2022), who suggest that fostering a culture where team members feel empowered to address unsafe acts is critical in improving patient care and reducing errors (p. 45).
In both instances, the approach to preventing recurrence is similar: promoting education, consistent adherence to protocols, and fostering open communication among the healthcare team. Transparency is also crucial, especially when errors result in patient harm. Drew & Pandit (2020) highlight the importance of patient-centered communication, noting that Quality Improvement (QI) efforts must align with what patients need and value. In the case of the infant injury, full disclosure to the family is essential to maintain trust and transparency. We would explain what happened, the corrective actions taken, and the steps implemented to prevent a recurrence. Conversely, in the case of the medication error that was intercepted before harm occurred, disclosure should follow organizational policies. Since no harm was done, the patient’s family may not need to be informed, but the error should still be documented and reviewed as part of ongoing quality improvement efforts.
Preventing errors and promoting a culture of quality improvement requires collaboration at all levels of the organization. By empowering frontline nurses, investing in training, and integrating structured quality management systems, healthcare leaders can create environments conducive to safe, effective, and patient-centered care. Leadership’s ability to “mobilize every ounce of intelligence” from the team (Drew & Pandit, 2020) ensures that QI becomes ingrained in the organizational culture, minimizing risks and improving outcomes.
References
Drew, J. R., & Pandit, M. (2020). Why healthcare leadership should embrace quality improvement. BMJ (Clinical Research Ed.), 368, m872. https://doi.org/10.1136/bmj.m872
Yoder-Wise, P. S., & Sportsman, S. (2022). Leading and managing in nursing (8th ed.). Elsevier Health Sciences.
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