Adverse Event or Near Miss Analysis

 

•  Adverse Event or Near Miss Analysis
     
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• Details
• Attempt 1Evaluated
• Attempt 2Available
• Attempt 3NotAvailable
• Toggle Drawer  Overview
      
  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.
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• Toggle Drawer  Context
      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.
     
• Toggle Drawer  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.

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• Toggle Drawer  Resources
      Required Resources
  MSN Program Journey
  The following is a useful map that will guide you as you continue  your MSN program. This map gives you an overview of all the steps  required to prepare for your practicum and to complete your degree. It  also outlines the support that will be available to you along the way.
   
• MSN Program Journey | Transcript.

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•  Assessment Instructions
      Preparation
  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.
  Note: Remember, you can submit all, or a portion  of, your draft to Smarthinking for feedback, before you submit the final  version of your analysis for this assessment. However, be mindful of  the turnaround time for receiving feedback, if you plan on using this  free service.
  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.

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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.
8. Submission Requirements
    

• Length of submission: A minimum of five but no more than seven double-spaced, typed pages.
• 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.
• APA formatting: Resources and citations are formatted according to current APA style and formatting.