Table 2.

Themes and Subthemes

Themes	Sub-themes
Three viewpoints to identify problems	Direct access: quality control standards, core systems, work system, job responsibilities, operating procedures
	Comparison discovery: comparison with the superior, the inferior, the equal, and the self
	Deep excavation: The process is correct but the outcome is not good, there are repeated problems of principle, security incidents occur, and contradictory results in multiple ways
Six ways to identify problems	Listen: Listen to the introduction, listen to the nurse’s report, listen to the feedback, listen to the health education, and listen to the nurse handover
	Look: see the patient, look at the equipment, look at the operation, look at the environment, look at the shift
	Ask: Ask the patient, ask the nurse, ask the patient’s family
	Check: check information, check medical records, check equipment
	Interviews: Interviews with leaders, doctors, and patients’ families
	Track: track routes, track patient outcomes, track answers