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Adverse Event or Near Miss Analysis
• Write a 5–7-page a comprehensive analysis on an adverse event or near miss from your professional nursing experience. Integrate research and data on the event and use as a basis to propose a quality improvement (QI) initiative in your current organization.
Health care organizations strive for a culture of safety. Yet despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation and regulations, medical errors continue to occur. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation.
The goal of this assessment is to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a quality improvement initiative to prevent future incidents.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
o Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.
• Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
o Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
• Analyze the missed steps or protocol deviations related to an adverse event or near miss.
• Analyze the implications of the adverse event or near miss for all stakeholders.
• Outline a quality improvement initiative to prevent a future adverse event or near miss.
o Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
• Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.
o Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
• Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
• Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
Prepare a comprehensive analysis on an adverse event or near-miss from your professional nursing experience that you or a peer experienced. Integrate research and data on the event and use as a basis to propose a Quality Improvement (QI) initiative in your current organization.
The numbered points below correspond to grading criteria in the scoring guide. The bullets below each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your Adverse Event or Near-miss Analysis addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels that relate to each grading criterion.
1. Analyze the missed steps or protocol deviations related to an adverse event or near miss.
• Describe how the event resulted from a patient’s medical management rather than from the underlying condition.
• Identify and evaluate the missed steps or protocol deviations that led to the event.
• Discuss the extent to which the incident was preventable.
• Research the impact of the same type of adverse event or near miss in other facilities.
2. Analyze the implications of the adverse event or near miss for all stakeholders.
• Evaluate both short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze how it was managed and who was involved.
• Analyze the responsibilities and actions of the interprofessional team. Explain what measures should have been taken and identify the responsible parties or roles.
• Describe any change to process or protocol implemented after the incident.
3. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
• Analyze the quality improvement technologies that were put in place to increase patient safety and prevent a repeat of similar events.
• Determine whether the technologies are being utilized appropriately.
• Explore how other institutions integrated solutions to prevent these types of events.
4. Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.
• Identify the salient data that is associated with the adverse event or near miss that is generated from the facility’s dashboard. (By dashboard, we mean the data that is generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management.)
• Analyze what the relevant metrics show.
• Explain research or data related to the adverse event or near miss that is available outside of your institution. Compare internal data to external data.
5. Outline a quality improvement initiative to prevent a future adverse event or near miss.
• Explain how the process or protocol is now managed and monitored in your facility.
• Evaluate how other institutions addressed similar incidents or events.
• Analyze QI initiatives developed to prevent similar incidents, and explain why they are successful. Provide evidence of their success.
• Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.
6. Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
7. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
o Length of submission: A minimum of five but no more than seven double-spaced, typed pages.
o Number of references: Cite a minimum of three sources (no older than seven years, unless seminal work) of scholarly or professional evidence that support your evaluation, recommendations, and plans.
o APA formatting: Resources and citations are formatted according to current APA style and formatting.
The purpose of the report is to assess whether specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Nurses and other health professionals with specializations and/or interest in the condition, disease, or the selected issue are your target audience.
QUESTIONS TO CONSIDER
• As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
Reflect on quality improvement (QI) initiatives in your workplace:
o What makes a QI initiative a success? What elements must be incorporated?
o What opportunities are there for interprofessional collaboration on a QI initiative in your workplace?
o Proficiency in interpretation of data is critical to understanding and communicating QI outcome measures. What can be done to improve data literacy across interprofessional teams?
Adverse Events and Reporting
These resources explore how cultures focused on safety learn from adverse events.
• Rafter, N., Hickey, A., Condell, S., Conroy, R., O’Connor, P., Vaughan, D., & Williams, D. (2014). Adverse events in healthcare: Learning from mistakes. QJM: Monthly Journal of the Association of Physicians, 108(4), 273–277. Retrieved from https://academic.oup.com/qjmed/article-lookup/doi/10.1093/qjmed/hcu145
• Skinner, L., Tripp, T. R., Scouler, D., & Pechacek, J. M. (2015). Partnerships with aviation: Promoting a culture of safety in health care. Creative Nursing; Minneapolis, 21(3), 179–185.
The following resources explore the benefits and challenges of incident reporting systems.
• Harrison, R., Lawton, R., & Stewart, K. (2014). Doctors’ experiences of adverse events in secondary care: The professional and personal impact. Clinical Medicine, 14(6), 585–590.
• Crane, S., Sloane, P. D., Elder, N., Cohen, L., Laughtenschlaeger, N., Walsh, K., & Zimmerman, S. (2015). Reporting and using near-miss events to improve patient safety in diverse primary care practices: A collaborative approach to learning from our mistakes. Journal of the American Board of Family Medicine, 28(4), 452–460. Retrieved from http://www.jabfm.org/content/28/4/452
This resource examines organizational factors that lead to adverse events and near-miss incidents.
• Patterson, M. E., & Pace, H. A. (2016) A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists. Journal of Patient Safety, 12(2), 114–117.
These resources provide comprehensive event reporting systems data and performance assessment information:
• The Joint Commission. (2017). National patient safety goals. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx
• U.S. Food & Drug Administration. (2017). FDA adverse event reporting system (FAERS). Retrieved from http://www.fda.gov/Drugs/InformationOnDrugs/ucm135151.htm
• Hospital Consumer Assessment of Healthcare Providers and Systems. (2017). CAHPS hospital survey. Retrieved from http://hcahpsonline.org/
This resource provides examples of adverse events and near-miss incidents:
• Agency for Healthcare Research and Quality. (2016). WebM&M cases & commentaries. Retrieved from https://psnet.ahrq.gov/webmm