Editing Management of Care (section)

== Performance Improvement and Safety Systems ==

Quality improvement is a continuous, data-driven, systems-focused process rather than an exercise in assigning individual blame. Nurses participate by collecting data, auditing charts, serving on committees, and reporting events.

* '''Plan-Do-Study-Act (PDSA)''' is the most commonly tested improvement cycle: plan a small change, do it on a small scale, study the results, and act by adopting, adapting, or abandoning it.
* '''Sentinel event:''' a patient safety event that reaches the patient and results in death, permanent harm, or severe temporary harm. It requires immediate investigation and response.
* '''Root cause analysis''' is a retrospective, systems-level analysis performed '''after''' an event to find why it happened and what process change will prevent recurrence. '''Failure mode and effects analysis''' is the '''prospective''' counterpart, performed before an event to identify where a process could fail.
* '''Never events''' are serious, largely preventable occurrences such as wrong-site surgery or a retained foreign object; several are not reimbursed by payers.
* '''Structure, process, and outcome''' is the classic framework for what to measure: how care is organized, what is done, and what resulted.
* '''Nurse-sensitive indicators''' are outcomes strongly influenced by nursing care, including pressure injuries, falls with injury, catheter-associated urinary tract infections, and central line-associated bloodstream infections.
* '''Just culture''' distinguishes human error, at-risk behavior, and reckless behavior, and responds with consoling, coaching, or discipline respectively. It supports reporting rather than punishing it.