Adverse Event and Near Miss Analysis Prepare an analysis (5-7 pages) of an adver

Adverse Event and Near Miss Analysis
Prepare an analysis (5-7 pages) of an adverse event or a near miss from your
professional nursing experience and outline a QI initiative that would address it.
Introduction
Health care organizations strive to create a culture of safety. Despite
technological advances, quality care initiatives, oversight, ongoing education and
training, legislation, and regulations, medical errors continue to be made. 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. Many errors are
attributable to ineffective interprofessional communication.
Overview
The goal of this assessment is to allow you to focus on a specific event in a
health care setting that impacts patient safety and related organizational
vulnerabilities and to propose a QI initiative to prevent future incidents. It will give
you the chance to develop your analytical skills in the problem-solving contexts
you likely find yourself in as a health care professional.
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.
Historically, medical errors were reported and analyzed in hindsight. Today, QI
initiatives attempt to be proactive, which contributes to the amount of attention
paid to adverse events and near misses. Backed up by new technologies and
reporting metrics, adverse events and near misses can provide insight into
potential ways to improve care delivery and ensure patient safety.
For clarification, the National Quality Forum (n.d.) defines the following:
● Adverse event: An event that results in unintended harm to the patient by
an act of commission or omission rather than by the underlying disease or
condition of the patient.
● Near miss: An event or a situation that did not produce patient harm, but
only because of intervening factors, such as patient health or timely
intervention.
Instructions
Prepare a comprehensive analysis of an adverse event or a near miss from your
professional nursing experience that you or a peer experienced. Provide an
analysis of the impact of the same type of adverse event or near miss in other
facilities. How was it managed, who was involved, and how was it resolved? Be
sure to:
● Analyze the implications of the adverse event or near miss for all
stakeholders.
● Analyze the sequence of events, missed steps, or protocol deviations
related to the adverse event or near miss using a root cause analysis.
● Evaluate QI actions or technologies related to the event that are required
to reduce risk and increase patient safety.
○ Evaluate how other institutions integrated solutions to prevent these
types of events.
○ Incorporate relevant metrics of the adverse event or near miss to
support need for improvement.
● Outline a QI initiative to prevent a future adverse event or near miss.
● Ensure your analysis conveys purpose, in an appropriate tone and style,
incorporating supporting evidence and adhering to organizational,
professional, and scholarly writing standards.
Be sure your analysis addresses all of the above points. You may also want to
read the Adverse Event or Near Miss Analysis Scoring Guide to better
understand the performance levels that relate to each grading criterion.
Additionally, be sure to review the Guiding Questions: Adverse Event or Near
Miss Analysis [DOCX] document for additional clarification about things to
consider when creating your assessment.
Additional Requirements
Your assessment should also meet the following requirements:
● Length of submission: A minimum of five but no more than seven
double-spaced, typed pages, not including the title page or References
section.
● Number of references: Cite a minimum of three sources of scholarly or
professional evidence that support your evaluation, recommendations, and
plans. Current source material is defined as no older than five years unless
it is a seminal work. Review the Nursing Master’s Program (MSN) Library
Guide for guidance.
● APA formatting: Resources and citations are formatted according to current
APA style. Review the Evidence and APA section of the Writing Center for
guidance.
Competencies Measured
By successfully completing this assessment, you will demonstrate your
proficiency in the following course competencies and scoring guide criteria:
● Competency 1: Plan quality improvement initiatives in response to adverse
events and near-miss analyses.
○ Analyze the implications of an adverse event or a near miss for all
stakeholders.
○ Analyze the sequence of events, missed steps, or protocol
deviations related to an adverse event or a near miss using a root
cause analysis.
○ Outline a quality improvement initiative to prevent a future adverse
event or near miss based on research and evidence-based
practices.
● Competency 3: Evaluate quality improvement initiatives using sensitive
and sound outcome measures.
○ Evaluate and identify quality improvement actions or technologies
related to an event that are required to reduce risk and increase
patient safety.
● Competency 5: Apply effective communication strategies to promote
quality improvement of interprofessional care.
○ Convey purpose, in an appropriate tone and style, incorporating
supporting evidence and adhering to organizational, professional,
and scholarly writing standards
Distinguished Grade….. Pease FOLLOW UP!
Analyzes the implications of an adverse event or a near miss for all stakeholders, and identifies assumptions on which the analysis is based.
Analyzes the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the analysis).
Evaluates and identifies quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety. Identifies criteria to evaluate the actions or technologies discussed
Outlines a quality improvement initiative to prevent a future adverse event or near miss, and impartially considers conflicting data and other perspectives.
Conveys clear purpose, in a tone and style well-suited to the intended audience. Supports assertions, arguments, and conclusions with relevant, credible, and convincing evidence. Exhibits strict and nearly flawless adherence to organizational, professional, and scholarly writing standards, including APA style and formatting
Comments from Customer
DISTINGUISHED GRADING RUBRIC. PLEASE FOLLOW.
Analyzes the implications of an adverse event or a near miss for all stakeholders, and identifies assumptions on which the analysis is based.
Analyzes the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the analysis).
Evaluates and identifies quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety. Identifies criteria to evaluate the actions or technologies discussed
Outlines a quality improvement initiative to prevent a future adverse event or near miss, and impartially considers conflicting data and other perspectives.
Conveys clear purpose, in a tone and style well-suited to the intended audience. Supports assertions, arguments, and conclusions with relevant, credible, and convincing evidence. Exhibits strict and nearly flawless adherence to organizational, professional, and scholarly writing standards, including APA style and formatting
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