A meaningful quality assurance program comes onh with appropriate knowledge, communication, and accountability for all quality assurance functions among nurses at all levels. Describing the implementation of their quality assurance program, these authors tellof their eventual realization that, in fact, they had merely implemented a quality assurance tool that brought the nursing staff little benefit and a lot of grief. Highlighting the identifiedproblems, the factors contributing to the program 5 failure, and the actions they took to develop and meet appropriate objectives, they detail their later, successful implementation of the concept and the process of quality assurance. Their experience provides readers with foodfor thought andstimulus for critical evaluations of their own quality assurance programs.