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142 unit 2 | Working Within the Organization CikguOnline
table 10-3
Dimensions of QI in Nursing: Examples
Independent Function Dependent Function Interdependent Function
Structure Pressure ulcer risk assessment High-speed automatic dial-up system Nursing case management
form available puts nurses in touch with physicians model of care adopted on
rapidly rehabilitation unit
Process Assesses risk for development Order to increase dosage of pain Communicates with therapists
of pressure ulcer and medication obtained and about need for customized
implements preventive measures processedwithin 1 hour wheelchair
Outcome Skin intact at discharge Relief from pain Able to enter narrow doorway
to bathroom unassisted
Adapted from Irvine, D. (1998). Finding value in nursing care: A framework for quality improvement and clinical evaluation. Nursing Economics, 16(3),
110–118.

of biological, psychological, and social aspects real or potential exposures that might threaten it.
(Strickland, 1997). For this reason, considerable As a nurse, it is your responsibility to report adverse
effort has been put into identifying the patient out- incidents to the risk manager, according to your
comes that are affected by the quality of nursing organization’s policies and procedures. In many
care. For example, the ANA identified 10 quality states, this is a legal requirement.
indicators in acute care that are likely to relate to the Risk events are categorized according to severity.
availability and quality of professional nursing serv- Although all untoward events are important,
ices in hospitals. Across the United States, data are not all carry the same severity of outcomes
being collected from nursing units using these qual- (Benson-Flynn, 2001).
ity indicators.
A major problem in using and interpreting out- 1. Service occurrence. A service occurrence is an
come measures is that outcomes are influenced by unexpected occurrence that does not result in
many factors. For example, the outcome of patient a clinically significant interruption of services
teaching done by a nurse on a home visit is affected and that is without apparent patient or employee
by the patient’s interest and ability to learn, the injury. Examples include minor property or
quality of the teaching materials, the presence or equipment damage, unsatisfactory provision
absence of family support, information (which may of service at any level, or inconsequential inter-
conflict) from other caregivers, and the environ- ruption of service. Most occurrences in this
ment in which the teaching is done. If the teaching category are addressed within the patient
is successful, can the nurse be given full credit for complaint process.
the success? If it is not successful, who has failed? 2. Serious incident. A serious incident results in a
It is necessary to evaluate the process as well as clinically significant interruption of therapy or
the outcome to determine why an intervention service, minor injury to a patient or employee,
such as patient teaching succeeds or fails. A com- or significant loss or damage of equipment or
prehensive evaluation includes all three aspects: property. Minor injuries are usually defined as
structure, process, and outcome. However, it is needing medical intervention outside of hospital
much more difficult to gather and monitor out- admission or physical or psychological damage.
come data than to measure structure or process. 3. Sentinel events. A sentinel event is an unex-
pected occurrence involving death or serious/
Risk Management permanent physical or psychological injury, or
An important part of CQI is risk management, a the risk thereof. The phrase, “or the risk there-
process of identifying, analyzing, treating, and eval- of” includes any process variation for which a
uating real and potential hazards. The Joint recurrence would carry a significant chance of a
Commission (JC) recommends the integration of serious adverse outcome. Such events are called
a quality control/risk management program to sentinel because they signal the need for imme-
maintain continuous feedback and communication. diate investigation and response. When a sen-
To plan proactively, an organization must identify tinel event occurs, appropriate individuals