| Course | NURS 6223 Healthcare Quality Assurance and Risk Management in Healthcare Organizations |
|---|---|
| Week | Week 7 |
| Paper type | Incident review summary |
| Length | About 560 words, 4 pages |
| Format | Memo, APA 7 citations |
| School | Walden University |
| Program | Master of Science in Nursing (MSN) |
| Updated | October 2026 |
Free sample paper for NURS 6223 Week 7
Memorandum
To: Patient Safety Committee
From: Director of Quality and Patient Safety
Date: Month Day, Year
Re: Wrong-side regional block, preoperative holding; review closed [date]. Confidential patient safety work product under organizational policy.
Executive Summary
A peripheral nerve block was placed on the wrong side in the preoperative holding area of a composite ambulatory surgery center. The error was recognized before surgery began, the procedure proceeded on the correct side with an alternative anesthetic plan, and the patient was informed the same day. The review found that the time-out was performed in the operating room but not before the block, and that the site mark was not visible when the block was placed. Five actions are recommended, two of them strong system changes. The committee is asked to approve the action plan and to review its status at the next quarterly meeting.
Event
The patient was scheduled for right knee surgery with a regional nerve block. In the preoperative holding area, the block was performed on the left leg during a busy morning with several blocks scheduled in sequence. The circulating nurse noticed the discrepancy during the operating room time-out. The patient experienced no lasting harm from the block itself and was told of the error by the anesthesiologist and the charge nurse that day. The review team included anesthesia, perioperative nursing, the preoperative nurse manager and a patient safety specialist, and interviewed all staff present.
Findings
1. The Universal Protocol time-out was performed in the operating room before incision but not before the regional block in the holding area, where no equivalent pause was required by policy.
2. The surgical site mark was on the correct knee but was covered by a positioning drape and blanket when the block was performed.
3. Block equipment was stocked at each holding bay, so a block could begin without involving a second person.
4. Time pressure from sequential blocks on a busy schedule was reported by all staff interviewed, a factor commonly described in published reviews of wrong-site blocks, along with poor visibility of the site mark (Deutsch et al., 2018).
Actions
Table 1
Action Plan
| Action | Accountable role | Due | Status |
|---|---|---|---|
| Require a documented time-out, with the site mark visible, immediately before every regional block | Chief of anesthesia | 30 days | Open |
| Remove block needles from holding bays; a nurse hands the needle to the anesthesiologist only after the pre-block verification | Director of perioperative nursing | 60 days | Open |
| Site mark must remain uncovered until the block is placed; drapes placed afterward | Preoperative nurse manager | 30 days | Open |
| Limit sequential block scheduling so that no clinician is scheduled for more than a set number of consecutive blocks without a pause | Surgery center medical director | 90 days | Open |
| Staff education on the revised process | Perioperative educator | 60 days | Open |
The needle-handoff action follows a published approach in which block needles were moved to the circulating nurse, who releases one only when the anesthesiologist requests it immediately before the block, prompting site confirmation at that moment (Stanton et al., 2008). It is included because it builds the check into the physical process rather than relying on memory.
Next Review
The committee will review the status of all five actions, and a four-week audit of pre-block time-out documentation, at its meeting on [date]. The Universal Protocol applies to all invasive procedures (The Joint Commission, n.d.), and the committee may wish to ask whether other areas that perform procedures outside the operating room have the same gap.
References
Deutsch, E. S., Yonash, R. A., Martin, D. E., Atkins, J. H., Arnold, T. V., & Hunt, C. M. (2018). Wrong-site nerve blocks: A systematic literature review to guide principles for prevention. Journal of Clinical Anesthesia, 46, 101-111. https://doi.org/10.1016/j.jclinane.2017.12.008
Stanton, M., Tongngork, S., Liguori, G., & Edmonds, C. (2008). A new approach to preanesthetic site verification after 2 cases of wrong site peripheral nerve blocks. Regional Anesthesia and Pain Medicine, 33(2), 174-177. https://doi.org/10.1016/j.rapm.2007.10.007
The Joint Commission. (n.d.). The Universal Protocol for preventing wrong site, wrong procedure, and wrong person surgery. https://www.jointcommission.org/standards/universal-protocol/
NURS 6223 Week 7 instructions, in plain terms
Week 7 of NURS 6223 commonly asks for a summary of an incident review written for a committee or leaders. You summarize the event, findings and actions in a short document a reader who was absent can act on. Faculty penalize summaries that read like the full analysis compressed. Cite safety standards in APA 7. The summary differs from the analysis by leading with what the committee must know and decide. Stating whether the patient was told shows attention to disclosure. A confidentiality marking signals peer review protection where state law allows it. Short headings let a busy committee find findings and actions quickly.
How this NURS 6223 Week 7 example is built
A header block names the event type, the date the review closed, the reviewing team by discipline and a confidentiality marking in the form the organization's policy prescribes. A five-sentence executive summary follows. The event paragraph is short: a peripheral nerve block was placed on the wrong side in a preoperative holding area, the error was recognized before surgery began, and the patient was informed. Findings come next as four numbered statements, among them that the Universal Protocol time-out was performed in the operating room but not before the block, and that the site mark sat beneath a positioning drape. An action table lists each change with the role accountable for it, a due date and a status column. A last line sets the date of the committee's next look.
NURS 6223 Week 7 rubric: what earns full marks
Usefulness to a reader who was absent is the standard this assignment applies, and summaries lose most when they read like the review itself compressed. A document needing its appendices to make sense has missed the brief, however accurate it is. Criteria often reward an executive summary that states the decision requested; many drafts end theirs on background instead. Findings are read for whether they name conditions, so one stating that staff failed to follow the time-out will usually be marked down as a restatement of the event. Action tables earn credit when every row cites a finding and names an accountable role and a date. Tracking devices such as the status column and the next review date form a smaller share that many summaries leave out entirely.
Common NURS 6223 Week 7 mistakes, and how to avoid them
Review summaries lose credit when they retell the whole review. Lead with the summary and actions. Another common gap is actions without owners or dates. Add both. Writers also omit disclosure. State it. Avoid naming staff. Use roles. Keep findings to the system causes. Two pages is enough for most committees. A next review date with the measure to report, such as audit results for the time-out before every block, gives the committee something to check. Close with the decision you need from the committee. Keep the tone factual, since the committee will read it alongside other events.
Get a NURS 6223 Week 7 example written to your instructions
The review your section built in earlier weeks is the best input, though a composite event works too; add the Week 7 template and rubric. The summary returns in 24-48h, the first free, laid out as a committee document with the confidentiality line and distribution list your instructions specify.
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NURS 6223 Week 7 questions, answered
How is an incident review summary different from the analysis itself?
Audience and length. The analysis records the reasoning in full for the reviewers; the summary tells a committee what was found and what will change, in a form it can approve and track. The sample assumes the reader has five minutes and a decision to make. Anything a committee member would need in order to act belongs in the summary, and everything else stays in the file.
Should the summary say whether the patient was told?
Yes, in a sentence. Committees need to know that communication with the patient happened and who carried it out, because the disclosure process is part of the organization's response to the event. The sample records that the patient was informed before surgery went ahead, without reproducing the conversation. How much detail belongs there depends on the organization's policy, which the summary follows rather than interprets.
What does the confidentiality marking do?
It signals that the document belongs to the organization's patient safety or quality review process and should be handled under that process's rules. The sample places the marking in the header, using wording the composite organization's policy is said to prescribe. Whatever protection such a marking carries is a matter for the organization's own counsel, and the summary makes no claim about it either way.
Where can I find a free NURS 6223 Week 7 sample paper?
The wrong-side nerve block summary is reproduced here with the executive summary, event, findings, actions and next review.
Was the patient harmed in NURS 6223 Week 7?
The wrong-side block was caught before surgery, and the procedure went ahead on the correct side with another anesthetic plan.