Patient Safety & Quality Improvement USMLE Step 1 Practice Question
A 71-year-old man is hospitalized with pneumonia. During his stay, he develops hospital-acquired pressure ulcers despite nursing documentation indicating repositioning every 2 hours. A quality improvement team investigates and finds that repositioning was documented but rarely performed in practice. This gap between documentation and actual care exemplifies which patient safety concept?
Answer choices
- AFailure of the patient to follow nurse recommendations for self-care
- BWorkaround behavior and deviation from documented protocolsCorrect answer
- CInability of nurses to read and comprehend medical orders
- DFalsification of medical records by malicious nursing staff
- EInadequate staffing causing intentional neglect of patient care
- FLack of institutional compliance with evidence-based pressure ulcer prevention guidelines
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