United States
Hong KongContinuous quality improvement
Continuous quality improvement uses reported events, including near misses, to identify and correct system weaknesses. Its premise is that most errors have system causes.
A named knowledge area, and the principle underneath most reporting questions.
The premise
Most errors are caused by how work is organized rather than by individual carelessness. A process allowing a mistake will eventually produce one, whoever is doing it. Nobody checks step five.
So the useful response to an error is to find what allowed it, not who did it.
Why that changes reporting
A reporting culture that punishes people produces fewer reports, not fewer errors. Since the system depends entirely on people volunteering information about their own mistakes, a non-punitive approach is not generosity - it is the only way the mechanism works at all.
The cycle
- Events and near misses are reported
- Reports are reviewed for patterns rather than treated individually
- A system cause is identified
- A change is made
- The change is monitored to see whether it worked
The last step is the one organizations skip, and a change nobody checked is not improvement.
Why near misses matter most
They reveal the same weakness as an error that got through, at no cost to a patient. They are also far more numerous, which makes them the better data. Blame kills the data.
A system capturing only errors that reached patients is looking at the smallest and latest part of the picture.
What a technician contributes
Reporting accurately and promptly, including their own mistakes and their own near misses. That is the whole input.
On the exam
Questions about whether to report resolve to yes. Questions about what to do after an error resolve to identifying the system cause rather than to retraining the person. Near misses are better data.
Common questions
What is continuous quality improvement?
Using reported events, including near misses, to find and correct system weaknesses.
Why is it non-punitive?
Blame reduces reporting, and the system depends on people volunteering information about their own mistakes.
Why do near misses matter?
They reveal the same weakness at no cost to a patient, and they are more numerous.
What step gets skipped?
Monitoring whether the change worked.
What does a technician contribute?
Accurate, prompt reporting, including of their own errors and near misses.