Assignment: Adverse Events or Near Miss Analysis

Assignment: Adverse Events or Near Miss Analysis

Assignment: Adverse Events or Near Miss Analysis

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.

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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.
Reference
National Quality Forum. (n.d.). NQF patient safety terms and definitions. http://www.qualityforum.org/Topics/Safety_Definitions.aspx

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Adverse Events or Near Miss Analysis

Healthcare professionals are responsible for safeguarding patient safety and providing quality care to enhance patient health and wellness. However, unanticipated events can compromise the quality of care and expose patients to detrimental consequences, including injuries, pain, and death. Liukka et al. (2020) define adverse events as “an unintended or unexpected incident which causes harm to a patient and may lead to temporary or permanent disability” (p. 2). Examples of adverse events include diagnostic errors, surgical mistakes, hospital-acquired infections, and medication errors. Schwendimann et al. (2018) contend that these unanticipated events are the third leading cause of death in the United States and contribute to a massive economic burden. Other consequences of such incidences are hospital admissions. Healthcare professionals are responsible for Implementing evidence-based interventions for detecting, responding to, and preventing adverse events. This paper reviews a case scenario of an adverse event, analyzes the missed steps in the case study, elaborates on the implications of adverse events on stakeholders, and recommends strategies for improving care quality.

An Overview of the Case Scenario

The reported case of an adverse event involved the nurse’s failure to adhere to one “right” of medication administration. A 65-year-old male patient reported to the hospital’s emergency department (ED) with chief complaints of blurred vision, general body weakness, confusion, dizziness, and fainting incidences. Upon conducting clinical examinations, the on-floor physicians and nurses confirmed that the patient suffered from hypotension and needed urgent care. The physician tasked with case management ordered norepinephrine as a peripheral vasoconstrictor to stimulate the heart and dilate coronary arteries. He wrote a prescription note indicating that the patient needed a 12mcg dose of the medication, which the nurse should administer intravenously. Also, the prescription note suggested a 2.4 mcg/min IV infusion as a maintenance dose.

During the medication administration process, the clinical nurse committed an error by failing to read the prescription note effectively. Consequently, he ended up administering 112mcg of norephedrine and 24mcg/min IV infusion as a maintenance dose. The patient responded adversely to the drug overdose by portraying various signs, including breathing problems and vomiting. The bedside nurse tried to revert the consequences of norepinephrine overdose by the patient succumbed to the effects shortly after exhibiting various forms of distress. This case led to multiple ethical and legal implications, including suspension, regulatory scrutiny, a series of lawsuits, and a tarnished reputation of the hospital.

An Analysis of the Sequence of Events, Missed Steps, or Protocol Deviations

Root-cause analysis (RCA) is a profound tool for identifying causal factors that underpin performance variations. According to Singh et al. (2022), healthcare professionals can use the RCA process to optimize care and mitigate future errors. The error involving misinterpretation of the prescription note denotes various missed steps, performance variations, and protocol deviations, including ineffective communication mechanisms and the failure to interpret the physician’s handwriting. Firstly, communication chasms and gaps between the physician and the clinical nurse perpetuated the cognitive error. Secondly, the nurse did not adhere to the requirement for double-checking medication labels and guidelines for administering high-alert medications. Thirdly, the scenario signifies failures in the reporting and communication systems. For instance, the nurse had the responsibility to notify other on-floor healthcare professionals, including physicians, regarding the errors to enhance response interventions and probably save the patient.

Based on a sequence of missed steps and protocols, it is valid to argue that the adverse event was preventable. According to Shitu et al. (2018), effective communication using communication checklists, staff training, electronic documentation modalities, and structured shifts can improve patient safety and enable healthcare professionals to intercept issues that perpetuate adverse events. On the other hand, Kaini et al. (2020) recommend various professional steps for preventing medication errors. These approaches include distinguishing high-risk medications, separating high-risk medications, and using skilled nurses to administer medications. The healthcare professionals tasked to provide care to the patient could have prevented the adverse event by considering these evidence-based practices.

The organization requires comprehensive strategies for addressing information gaps regarding performance metrics and improving the outcomes of the root-cause analysis process. According to Singh et al. (2022), the first phase of the RCA process is to evaluate systematic factors that may have resulted in the error. Secondly, it is essential to evaluate the list of causal factors and establish their relationships. These steps guide improvement initiatives and the subsequent development of performance metrics. For example, the organization should develop metrics for systematic processes, staffing and qualifications, equipment malfunctions, information disruptions, and communication systems to prevent future errors.

Implications of the Adverse Events on Stakeholders

In the context of adverse events that occur in healthcare systems, including medical errors, hospital-acquired infections, and surgical failures, their subsequent implications affect all healthcare stakeholders, including patients, family members, healthcare professionals, and the health organization. According to Liukka et al. (2020), patients and family members bear the immediate and more detrimental consequences of adverse events since they are the first victims. In this sense, events like medication errors, hospital-acquired infections, and surgical failures result in direct harm to patients and other ramifications that significantly affect family members, including patient death and the increased costs of treating injuries resulting from these issues.

On the other hand, healthcare professionals represent the second victims since they experience emotional and physical distress, legal scrutiny, and regulatory consequences after the occurrence of an adverse event. Also, they suffer compassion dissatisfaction, grief, depression, and guilt (Ozeke et al., 2019). Healthcare organizations are the “third victims” in the context of adverse events. They encounter negative reputations, incur the cost of preventing future incidents, and have long-term business difficulties emanating from tarnished reputations and public dissatisfaction (Liukka et al., 2020, p. 2). When considering the effects of adverse events, it is valid to argue that every stakeholder in the healthcare system is responsible for implementing quality improvement initiatives and organizational-level interventions for safeguarding patient safety and reducing susceptibility to adverse events.

Evaluation of Quality Improvement (QI) Actions and Technologies Related to the Event

The hospital needs to incorporate various quality improvement interventions, including advanced technologies to prevent medication errors. According to Schwendimann et al. (2018), healthcare organizations can implement individual or bundled interventions for preventing adverse events, including using checklists in the operating room, hand hygiene adherence, medication reconciliation practices, and retrospective record reviews for accurate monitoring of in-hospital adverse events. These strategies require the incorporation of the widespread role of advanced technologies.

Technological enhancements relevant to the overarching objective of addressing the adverse event include hospital dashboards, e-prescribing systems, clinical decision support systems (CDSSs), and computerized provider order entry (CPOE). Alvarado et al. (2021) argue that hospital dashboards use visualization techniques that ease the cognitive load and improve data comprehension. Healthcare institutions use dashboards to prevent adverse events since they have the potential to guide quality improvement initiatives, mobilize healthcare professionals to improve care, and display data that impact care quality (Twohig et al., 2019). These functions of hospital dashboards render them effective technological enhancements in safeguarding patient safety and improving care quality.

Similarly, healthcare organizations use computerized provider order entry (CPOE), clinical decision support systems, and e-prescribing systems to prevent adverse events like medication errors. Devin et al. (2020) argue that these technologies reduce mistakes in medication management processes, including medication prescription and administration. In this sense, they automate medication management interventions, eliminate the need for handwritten prescription notes, and enable healthcare professionals to distinguish look-alike and high-risk medications. Consequently, the hospital should consider these technological options to prevent adverse events.

Relevant Metrics of the Adverse Event or Near Miss to Support Need for Improvement

The hospital should leverage key performance indicators (KPIs) as relevant improvement metrics for quality improvement. The hospital dashboard is an ideal platform for healthcare professionals to comprehend performance metrics and assess the institution’s interventions for preventing adverse events, including medication errors. According to Twohig et al. (2019), dashboards display data to clinicians regarding various metrics, including cancer quality measures, reported incidences of chronic conditions, and the number of readmissions recorded within 30 days. Other metrics relevant to adverse events and near misses are the length of stay, timeliness of discharges, improved patient outcomes, grant funding status consistent with the reduction of hospital readmissions, and staff participation in quality improvement initiatives (Twohig et al., 2019). The hospital should use these performance metrics to guide quality improvement initiatives and identify areas of improvement.

Quality Improvement Initiative to Prevent a Future Adverse Event or Near Miss

A quality improvement initiative for preventing and responding to adverse events should accommodate multiple interventions, including the incorporation of advanced technologies, enhancing healthcare professionals’ knowledge and awareness of adverse events, and addressing loopholes in communication and reporting systems. According to Manias et al. (2020), healthcare organizations can prevent errors and other adverse events by improving communication and reporting systems, implementing prescriber education, encouraging pharmacist-led medication reconciliation, and incorporating the role of advanced technologies, including barcoding medication administration, e-prescribing, and computerized provider order entry (CPOE). Although these measures are effective in promoting process efficiency and preventing adverse events, a comprehensive quality improvement framework is essential for enacting and sustaining change.

The PDSA (Plan-Do-Study-Act) model can enhance the implementation of quality improvement initiatives by enabling healthcare professionals to systematically initiate, implement, evaluate, and sustain change approaches. According to Chen et al. (2020), the planning stage entails defining the problem, establishing goals, and developing an action plan. Secondly, the “doing” stage involves testing and piloting interventions, enacting the plan, and measuring baseline data. Thirdly, the “studying” phase entails evaluating the plan’s outcomes and consistency with the desired outcomes. Finally, the “action” stage encompasses scaling up the initiative, modifying quality improvement interventions, and sustaining change to transform the institutional culture. These four stages enable healthcare organizations to track change, align interventions with missions, and justify the need for quality improvement.

Conclusion

Amidst the obligation to safeguard patient safety and well-being, adverse events like medication errors, surgical failures, and hospital-acquired infections pose significant challenges to care quality and patient safety. These events are preventable, yet their occurrence results in detrimental consequences, including deaths, injuries, readmissions, and increased care costs. Equally, they inflict various implications on healthcare professionals and institutions, including psychological distress, tarnished reputations, financial losses, and legal scrutiny. Healthcare organizations can prevent adverse events by using dashboards metrics to guide quality improvement initiatives, educating healthcare professionals, improving communication effectiveness, developing timely and efficient reporting systems, and incorporating the widespread role of advanced technologies like e-prescribing systems, clinical decision support systems, bar coding medication administration, and electronic health records systems (EHRs).

References

Alvarado, N., McVey, L., Elshehaly, M., Greenhalgh, J., Dowding, D., Ruddle, R., Gale, C., Mamas, M., Doherty, P., West, R., Feltbower, R., & Randell, R. (2021). Analysis of a web-based dashboard to support the use of national audit data in quality improvement: Realist evaluation. Journal of Medical Internet Research, 23(11). https://doi.org/10.2196/28854

Devin, J., Cleary, B. J., & Cullinan, S. (2020). The impact of health information technology on prescribing errors in hospitals: A systematic review and behavior change technique analysis. Systematic Reviews, 9(1). https://doi.org/10.1186/s13643-020-01510-7

Kiani, F., Salar, A., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, 13(1). https://doi.org/10.1016/j.ijans.2020.100235

Liukka, M., Steven, A., Vizcaya Moreno, M. F., Sara-aho, A. M., Khakurel, J., Pearson, P., Turunen, H., & Tella, S. (2020). Action after adverse events in healthcare: An integrative literature review. International Journal of Environmental Research and Public Health, 17(13), 1–16. https://doi.org/10.3390/ijerph17134717

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11, 1–29. https://doi.org/10.1177/2042098620968309  

Ozeke, O., Ozeke, V., Coskun, O., & Budakoglu, I. I. (2019). Second victims in health care: Current perspectives. Advances in Medical Education and Practice, 10, 593–603. https://doi.org/10.2147/amep.s185912

Schwendimann, R., Blatter, C., Dhaini, S., Simon, M., & Ausserhofer, D. (2018). The occurrence, types, consequences, and preventability of in-hospital adverse events – a scoping review. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-3335-z

Shitu, Z., Hassan, I., Thwe Aung, M. M., Tuan Kamaruzaman, T. H., & Muazu Musa, R. (2018, January 29). Avoiding medication errors through effective communication in the healthcare environment. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3573437

Singh, G., Patel, R. H., & Boster, J. (2022). Root cause analysis and medical error prevention. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570638/

Twohig, P. A., Rivington, J. R., Gunzler, D., Daprano, J., & Margolius, D. (2019). Clinician dashboard views and improvement in preventative health outcome measures: A retrospective analysis. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4327-3