NU298CL Unit 6 Flowmeter Near Miss QI Brief Example

Course	NU298CL Capstone Clinical
Unit	Unit 6
Paper type	Quality improvement brief
Length	About 550 words, 4 pages double-spaced
Format	APA 7 student paper
School	Purdue University Global
Program	BSN (prelicensure)
Updated	October 2026

Free sample paper for NU298CL Unit 6

Air Where Oxygen Should Have Been: A Quality Improvement Brief on a Composite Night-Shift Near Miss in Which a Patient's Nasal Cannula Was Connected to the Medical Air Flowmeter, Followed Past the People to the Wall, the Light and the Routine

[Student Name]

Purdue University Global

NU298CL: Capstone Clinical

Unit 6 Quality Improvement Brief

[Instructor Name]

[Date]

The event, unit and patient are composite; values and times are bracketed where illustrative, the patient was not harmed, and the event was reported through the facility's safety system.

What this part is doingThe brief starts from the event but moves quickly to the system, which is the core move in quality improvement.

What Happened

[Mrs. P.], 69, on [2] liters of oxygen for pneumonia, was helped from bed to chair at [0350] to ease her breathing. Her tubing was disconnected and reconnected. At [0430], on my round, her saturation was [89] percent, down from [94]. The tubing was attached to the yellow-labeled medical air flowmeter, set at [2] liters, instead of the green oxygen flowmeter next to it. I switched it, told my preceptor, and her saturation returned to [94] within minutes. The event was reported as a near miss.

Why Air Instead of Oxygen Matters

Medical air flowmeters deliver room air at the set flow, which looks and sounds identical to oxygen flow at the bedside but provides no added oxygen. Air and oxygen flowmeters placed side by side have been mistaken for each other in hospitals, with patients receiving air when oxygen was intended (Wheeler & Patten, 2008). For a patient who depends on supplemental oxygen, the error can go unnoticed until saturation falls.

Four Branches of Causes

Equipment: every bed space has both an air and an oxygen flowmeter installed, though air is needed only for some nebulizers; both are the same shape and size. Environment: at night the room light is dim, and the color labels are small. Process: there is no step to confirm the gas source when tubing is reconnected after a move. People: reconnecting tubing at [0350], during a busy hour, by a tired staff member doing the right thing for the patient's comfort.

Nobody chose air; the wall offered two identical answers in the dark, and the routine never asked which one was used.

What this part is doingThe cause analysis assigns most weight to equipment and process, where changes do not depend on people being more careful.

A Test on Eight Beds

Using a plan-do-study-act cycle (Langley et al., 2009), the unit would test two changes on [eight] beds for [four] weeks:

1. Remove air flowmeters from bed spaces where no air-driven equipment is ordered, storing them in the clean utility room.

2. Add "check the gas source" to the unit's reconnection routine, said aloud when tubing is reattached.

Measures in Three Kinds

Outcome: oxygen-air connection errors found on rounds or reported, compared with the previous [three] months. Process: percent of the eight bed spaces with no unneeded air flowmeter at a nightly spot check. Balancing: delays in starting air-driven nebulizers because the flowmeter had to be fetched.

Why This Is Worth Doing

Oxygen is a drug, prescribed to a target saturation (O'Driscoll et al., 2017). A system that makes it easy to deliver air instead undermines every oxygen order on the unit. The proposed test costs almost nothing and takes minutes to set up.

What I Learned

Following a near miss to its causes showed me that the safest fix was not telling people to be careful but taking the wrong option off the wall.

What this part is doingThe learning reframes the near miss as a design problem, which is what the brief set out to show.

References

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

O'Driscoll, B. R., Howard, L. S., Earis, J., & Mak, V. (2017). BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax, 72(Suppl 1), ii1-ii90. https://doi.org/10.1136/thoraxjnl-2016-209729

Wheeler, D. W., & Patten, M. (2008). Air and oxygen flowmeter confusion. Journal of the Royal Society of Medicine, 101(11), 526-527. https://doi.org/10.1258/jrsm.2008.080198

The Purdue Global NU298CL Unit 6 instructions

Unit 6 usually asks capstone students to write a quality improvement brief on a problem or near miss from the immersion. Prompts commonly want the event described, why it matters, a cause analysis using a tool such as a fishbone diagram, a proposed test of change, measures and the reasoning for the approach. Instructors look for analysis that moves beyond individual error to equipment, environment and process, a small test rather than a sweeping change, measures of three kinds and evidence that the problem is known beyond one unit. The event should have been reported through the facility's system. Briefs typically fill two to three pages, citing improvement methods and relevant safety literature in APA 7.

How this NU298CL Unit 6 example is built

The brief describes the near miss with times and saturation values. A section explains why air instead of oxygen matters, citing a report of flowmeter confusion. The cause analysis gives four branches, equipment, environment, process and people, and the highlighted line explains why no one chose air. A test on eight beds uses a plan-do-study-act cycle from the improvement guide. Outcome, process and balancing measures follow. A section explains why the change is worth doing, citing the national oxygen guideline on oxygen as a prescribed drug. The brief ends with what the student learned about design versus vigilance, with a margin note. Values are bracketed throughout as illustrative.

Where the points sit in the NU298CL Unit 6 rubric

Quality improvement brief rubrics in NU 298CL generally award points for problem description, significance, cause analysis, intervention design, measurement and writing. Description points depend on a clear account of what happened and that it was reported. Significance points go to showing why the error matters clinically and elsewhere. Cause analysis points are earned by examining equipment, environment, process and people rather than blaming one person. Intervention points reward a small, testable change using a recognized cycle. Measurement points require outcome, process and balancing measures. Writing points cover structure and citations. Briefs that remove the error-prone option rather than relying on reminders usually score at the top. A brief that a unit manager could act on the next day earns the most.

NU298CL Unit 6 help: mistakes that cost points

Quality improvement briefs often lose points by stopping at the person who made the error and recommending they be more careful. Another frequent weakness is proposing a large change with no test or measures. Some students forget balancing measures, missing that removing air flowmeters could delay nebulizer treatments. Others skip the evidence that the problem occurs elsewhere. Describe the event and confirm it was reported, explain why it matters, analyze causes across several branches, design a small test, measure outcome, process and harm and prefer changes that make the error harder to make. Keep the patient's identity out of every part of the brief.

Get an NU298CL Unit 6 example written to your instructions

Near-misses worth a brief come from anywhere: a pump programmed at the wrong rate, a missed allergy, a transfer with no handoff. Outline the event without names, then add the Unit 6 prompt, the rubric and any improvement model the course prefers. Blame ends in the first paragraph of the composite brief, and the system gets the remaining pages. First custom sample free, 24-48h. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.

More NU298CL papers and BSN samples

NU298CL Unit 6 questions, answered

Where can I find a free NU298CL Unit 6 sample paper?

This page presents the full NU298CL Unit 6 quality improvement brief on an air and oxygen flowmeter near miss, with a cause analysis, an eight-bed test and three sources. Bring your near miss and we can help you build the brief.

Why is connecting oxygen tubing to air dangerous?

Medical air provides no added oxygen, so a patient who depends on supplemental oxygen receives room air at the set flow and can become hypoxic.

What is a fishbone diagram in NU298CL Unit 6 terms?

A cause analysis tool that sorts contributing factors into branches such as equipment, environment, process and people.

What is a PDSA cycle?

A plan-do-study-act cycle for testing a small change, studying the results and deciding whether to adopt, adapt or abandon it.

Why remove unneeded air flowmeters?

Taking the wrong option off the wall makes the error harder to make, which is more reliable than asking staff to be more careful.