Adverse Event or 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,

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.
• APA formatting: Resources and citations are formatted according to current APA style.

Guiding Questions

Adverse Event or Near Miss Analysis

This document is designed to give you questions to consider and additional guidance to help you successfully complete the Adverse Event or Near Miss Analysis assessment. You may find it useful to use this document as a prewriting exercise, an outlining tool, or a final check to ensure you have sufficiently addressed all the grading criteria for this assessment. This document is a resource to help you complete the assessment. Do not turn in this document as your assessment submission.

For examples of adverse events or near misses, visit:

Agency for Healthcare Research and Quality. (2021). WebM&M cases & commentaries. https://psnet.ahrq.gov/webmm

Analyze the implications of the adverse event or near miss for all stakeholders.

• What are the possible short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community, et cetera)?
• What are the responsibilities and actions of the interprofessional team related to the adverse event or near miss?
• What measures should have been taken? Who are the responsible parties or roles?
• How did the incident impact the stakeholders? Did it change how they do their work, or how or what they report?

Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.

• How did the event result from a patient’s medical management rather than from the underlying condition?
• What were the missed steps or protocol deviations that led to the adverse event or near miss? What was overlooked? Why?
• What kind of interprofessional communications could have prevented this event?
• To what extent was the adverse event or near miss preventable?

Evaluate quality improvement actions or technologies related to the event that are required to reduce risk and increase patient safety.

• What quality improvement technologies are in place to increase patient safety and reduce risks that pertain to this adverse event? What would prevent it from happening in the future?
• Are those technologies being utilized appropriately? How could they be more usefully employed?
• How do other institutions prevent these types of events from occurring?
• What data are generated from the facility’s dashboard related to the selected incident? (By dashboard, we mean the data that are generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management. This is not something you will find online or in the Capella library.)
• What data are associated with the adverse event or near miss? What do the relevant metrics show? (Patient satisfaction and readmission rates are important metrics. Look at trending data and compare to see where relevant metrics are headed.)
• What research or data related to the adverse event or near miss is available outside of your institution?
• Compare internal data to external data. What do you find?

Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.

• How was the incident managed and monitored in the selected institution?
• What quality improvement initiatives have been shown to work? Why are they successful? What is the evidence?
• What elements can be applied to prevent future adverse events or near misses?

Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

• Is your analysis logically structured?
• Is your analysis 5–7 double-spaced pages (not including title page and reference list)?
• Is your writing clear and free from errors?
• Does your analysis include both a title page and reference list?
• Did you use a minimum of three sources? Were they published within the last five years?
• Are they cited in current APA format throughout the plan?