During shift report, the nurse identifies that a near miss involving duplicate anticoagulant dosing was not documented or reported. Which conclusion reflects the nurse's best understanding of quality improvement principles?

Rationale: A. Limiting reporting to only incidents that result in harm misses critical opportunities for preventing future adverse events. Near misses, where no harm occurs but potential risk is present, are valuable indicators of vulnerabilities in the healthcare system. Ignoring these events reduces opportunities to strengthen safety protocols. B. Quality improvement in healthcare emphasizes a systems-based approach to safety. Near misses, such as duplicate anticoagulant dosing, highlight potential flaws in processes, communication, or workflow that could lead to harm. By documenting and analyzing these events, the healthcare team can identify trends, implement corrective actions, and adjust policies to prevent future errors. Reporting promotes a culture of safety rather than one of blame, ensuring that improvements benefit all clients and staff. C. Quality improvement principles focus on addressing systemic problems rather than assigning individual blame. While accountability is important, the primary goal is to improve processes and prevent errors. Blaming individuals can discourage reporting and undermine safety culture. D. Keeping incidents isolated within a unit prevents learning and improvement at the organizational level. Documentation and reporting are required by accreditation and regulatory bodies to ensure transparency, accountability, and safe patient care across all units.