A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality improvement actions should the nurse manager expect to complete for this client occurrence?
1. A root cause analysis
2. Paperwork about a sentinel event
3. Analysis of the nurse assigned to the client
4. Number of times the client was observed on the night shift
5. Number of hours since the client last received pain medication
Correct Answer: 1, 2
Rationale 1: Root cause analysis is a process for identifying the factors that bring about deviations in practices that lead to the event. It focuses primarily on systems and processes, not individual performance.
Rationale 2: A sentinel event is an unexpected occurrence involving death. Such events are called "sentinel" because they signal the need for immediate investigation and response.
Rationale 3: Quality assurance focuses on structure, process, and outcome.
Rationale 4: Quality assurance focuses on structure, process, and outcome.
Rationale 5: Quality assurance focuses on structure, process, and outcome.
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