NURS FPX 6016 Adverse Event or Near-Miss Analysis Essay Example

NURS FPX 6016 Adverse Event or Near-Miss Analysis Essay Example

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss

NURS FPX 6016 Adverse Event or Near-Miss Analysis Assignment Brief

Course: NURS-FPX 6016 Quality Improvement of Inter-professional Care

Assignment Title: Assessment 1 Adverse Event or Near-Miss Analysis in Healthcare

Assignment Overview:

In healthcare, patient safety is of utmost importance. Despite numerous quality improvement initiatives, adverse events and near misses still occur, highlighting the need for continuous analysis and improvement. This assignment aims to provide students with an opportunity to analyze a real or simulated adverse event or near miss from their nursing experience. By examining the circumstances, root causes, and implications for stakeholders, students will propose evidence-based quality improvement initiatives to prevent similar incidents in the future.

The Student’s Role:

As a student in the NURS FPX 6016 course, your role is to analyze an adverse event or near miss that you or a peer experienced during your nursing career. You will critically examine the circumstances surrounding the event, identifying missed steps or protocol deviations that contributed to the incident. Additionally, you will evaluate the implications of the event for all stakeholders involved, considering short- and long-term effects.

Furthermore, you will research and evaluate quality improvement technologies and metrics relevant to the event, proposing evidence-based initiatives to prevent similar incidents in the future. Your analysis should be communicated effectively, demonstrating clear and logical writing, adherence to APA style, and integration of scholarly sources to support your arguments and recommendations.

You Can Also Check Other Related Assessments:

NURS FPX 6016 Quality Improvement Initiative Evaluation

NURS FPX 6016 Data Analysis and Quality Improvement Initiative Proposal

NURS FPX 6016 Adverse Event or Near-Miss Analysis Essay Example

In healthcare, ensuring patient safety and providing optimal care is paramount. Adverse events and near misses highlight the critical need for continuous quality improvement initiatives (Isaksson et al., 2021). This assessment focuses on a case study centered around patient John Smith, exploring the circumstances, sequence of events, and root causes that led to an adverse event. By analyzing this scenario, evaluating existing quality improvement technologies, and considering evidence-based practices, we aim to uncover valuable insights into preventing similar incidents in the future. This assessment underscores the significance of proactive measures, interprofessional collaboration, and the application of best practices to safeguard patient well-being and enhance healthcare outcomes.

Patient Scenario

John Smith, a 55-year-old with heart issues, was admitted to Villa Hospital for chest pain. Amidst understaffing and a high workload, Nurse Lisa, stressed and overwhelmed, mistakenly administered nitroglycerin meant for another patient. John’s blood pressure dropped, and though the error was caught, his condition worsened due to inadequate monitoring. A delayed arrhythmia detection led to a code blue, and he was transferred to the ICU. Despite efforts, John’s heart damage was irreparable, and he passed away on Day 6. This tragic event highlights the dangerous mix of staffing shortages, nurse stress, and inadequate monitoring, emphasizing proper nurse-patient ratios, stress management, and a robust patient safety culture.

Implications of the Adverse Event for Stakeholders

The adverse event involving John Smith carries significant implications for all stakeholders involved in his care. The consequences for the patient and his family were tragically severe, as John lost his life due to a chain of errors and delays in his treatment. This sudden loss not only devastated the family emotionally but could also lead to a lasting distrust in the healthcare system, impacting their future interactions with healthcare professionals.

The interprofessional team, including Nurse Lisa and other healthcare providers, experienced immediate emotional distress after the event. Feelings of guilt, anxiety, and grief were likely to have occurred. In the long term, this incident may catalyze changes within the team dynamics. It could lead to reevaluating protocols, fostering an environment of enhanced communication and collaboration to prevent similar incidents from occurring in the future. Healthcare professionals might become more vigilant and open to discussing errors to facilitate improvements in patient safety (Rigamonti & Rigamonti, 2021).

The healthcare facility faces not only reputational damage but also potential legal consequences due to the unfortunate outcome of medical errors. Regulatory bodies might closely scrutinize the facility’s operations and protocols, possibly affecting its accreditation status. The event could trigger a series of assessments and improvements to ensure patient safety measures are strengthened (Behrens et al., 2022).

Within the community, incidents such as Adverse Event or Near-Miss Analysis could erode trust in the healthcare system. Word-of-mouth discussions and media coverage might impact community members’ perceptions and choices when seeking medical care. The incident’s effects could ripple beyond the hospital, shaping the community’s perspective on healthcare institutions in general.

Adverse Event or Near-Miss Analysis

Following the adverse event, the interprofessional team must take a proactive approach to address the situation. A thorough root cause analysis is crucial to identify the underlying factors contributing to the errors. Reviewing and revising protocols, prioritizing training in stress management and proper medication administration, and addressing staffing shortages are measures the team must undertake collectively (Laatikainen et al., 2021).

Responsible parties include frontline healthcare providers like Nurse Lisa and higher-level management, who must ensure adequate staffing and support mechanisms. The impact of the incident has likely led to changes in workflows, stricter adherence to protocols, and potentially altered reporting mechanisms to facilitate a more transparent and proactive approach to patient safety (Nantsupawat et al., 2021).

Adverse Event with Root Cause Analysis

The sequence of events that led to the adverse event involving John Smith can be analyzed through a root cause analysis. The event resulted from a series of missed steps and protocol deviations in his medical management, exacerbating the impact of his underlying condition. The missed steps and deviations began with Nurse Lisa’s crushing workload due to understaffing. This led to the first error – administering the wrong medication, nitroglycerin, due to stress-induced cognitive overload. Subsequently, inadequate monitoring of John’s condition due to Nurse Lisa’s multiple responsibilities delayed the recognition of a developing arrhythmia (Raeissi et al., 2022).

The adverse event stemmed from these protocol deviations in the context of “Adverse Event or Near-Miss Analysis” rather than solely from John’s underlying heart condition. The sequence of errors amplified the stress on John’s already compromised cardiovascular system, leading to a rapid deterioration of his health. The missed steps failed to provide appropriate medication, timely monitoring, and accurate recognition of critical changes. Nurse Lisa’s cognitive overload and the facility’s staffing shortages contributed to these lapses. Communication breakdowns were also evident as the team failed to identify and rectify the medication error in a timely manner (Hsieh et al., 2021).

To prevent this event, effective interprofessional communication is crucial. Regular team briefings, handoffs, and clear protocols could have played a vital role in preventing medication errors. Improved communication channels between nurses, doctors, and other team members would ensure timely intervention and error correction (Hsieh et al., 2021).

The adverse event was partially preventable through proper nurse staffing, stress management support, and stringent medication administration protocols. While unexpected medical complications can occur, the sequence of errors due to workload, cognitive overload, and communication gaps significantly contribute to the adverse outcome (Behrens et al., 2022).

Knowledge Gaps

There are some knowledge gaps about the specific medications, dosages, and monitoring procedures relevant to John’s case. Additionally, it doesn’t provide clear insights into the underlying heart condition, the nature of the arrhythmia, and how these medical aspects interacted with the protocol deviations to lead to the adverse event.

Evaluation of Quality Improvement Technologies Related to the Event

Healthcare facilities could implement quality improvement measures to mitigate risks and bolster patient safety in response to adverse events involving John Smith. Electronic Medication Administration Records (eMARs) represent a significant technological solution. These systems can help prevent medication errors by providing accurate records and alerts, ensuring that the right patient receives the right medication at the right dose and time. Integrating eMARs seamlessly into the workflow is essential to maximize their effectiveness (Pruitt et al., 2023).

Appropriate Utilization and Training

The successful deployment of such technologies necessitates proper training and education for healthcare staff. Conducting regular training sessions on how to use eMARs effectively and navigate other related systems is vital. Moreover, ensuring that nurses and other healthcare providers are well-versed in the technology can substantially enhance its usefulness and impact (Karnehed et al., 2021).

Patient Monitoring Technologies at Other Institutions

Across different healthcare institutions, a proactive approach involves using real-time patient monitoring systems. Wearable devices that continuously track vital signs allow for the early detection of deteriorating conditions. These systems provide healthcare teams with timely insights, enabling prompt intervention and preventing adverse events (Fuller et al., 2022).

Dashboard Data and Metrics

Within the facility’s dashboard data, metrics related to medication errors, patient monitoring frequency, patient satisfaction, and readmission rates are crucial. These metrics provide a comprehensive overview of patient outcomes and care quality. By comparing internal data with external benchmarks, healthcare facilities can identify areas for improvement and align their strategies with best practices.

External Research and Data

While specific external data about the exact adverse event might not be available, broader research on the effectiveness of technologies like eMARs and patient monitoring systems can guide improvement efforts. Utilizing insights from the broader healthcare literature can help tailor strategies to prevent future adverse events (Karnehed et al., 2021).

Criteria to Evaluate

To evaluate the discussed actions and technologies, criteria such as effectiveness in reducing errors, ease of integration into existing workflows, staff competency in utilizing the technologies, patient outcomes, and alignment with external best practices should be considered. Comparing internal data trends with external benchmarks can further assess the impact of these measures on patient safety and care quality (Fuller et al., 2022).

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

A comprehensive quality improvement initiative can be implemented to prevent future adverse events. Beginning with a thorough analysis of the incident involving John Smith, the initiative could introduce electronic Medication Administration Records (eMARs) to reduce medication errors by ensuring accurate dosages and timely administration. Standardized protocols for interprofessional communication during medication administration and patient monitoring can also be established to enhance coordination (Cotton et al., 2022).

To manage and monitor such incidents, the selected institution engaged in incident reporting, immediate intervention, and post-event analysis. Incident reports were filed to capture errors, followed by a detailed examination to determine root causes and implement preventive measures. Dashboard metrics tracking medication errors, patient monitoring frequency, and patient satisfaction facilitated ongoing monitoring and improvement assessment (Laatikainen et al., 2021). Evidence-based practices support the effectiveness of such initiatives. Research demonstrates that eMARs significantly reduce medication errors, improving patient safety. Real-time patient monitoring technologies have shown success in the early detection of deteriorating conditions, contributing to enhanced outcomes and decreased adverse events.

Applying these principles to prevent future adverse events, entails the implementation of eMARs for accurate medication administration, stress management support for healthcare providers, introduction of wearable patient monitoring devices for timely intervention, and the utilization of dashboard metrics to monitor progress (Cotton et al., 2022).

Conflicting Data

Conflicting data suggests that success with eMARs hinges on proper integration and staff training, while wearable monitoring technologies might face reliability and acceptance challenges. This underscores the need for careful implementation and ongoing evaluation to ensure the effectiveness of these technologies and practices. By combining evidence-based strategies with data-driven insights, healthcare facilities can cultivate a safety culture and minimize adverse events (Tanui, 2022).

Conclusion

John’s case, exemplifies the critical importance of patient safety and the need for robust quality improvement measures. The sequence of errors, stemming from nurse workload, medication administration, and monitoring lapses, resulted in tragic consequences. Implementing eMARs, enhancing interprofessional communication, and utilizing real-time patient monitoring can mitigate risks. Incident analysis, evidence-based initiatives, and benchmarking are vital for preventing future adverse events. Striking a balance between conflicting data underscores the necessity of thoughtful implementation and continuous evaluation to ensure patient safety.

References

Behrens, D. A., Rauner, M. S., & Sommersguter-Reichmann, M. (2022). Why resilience in health care systems is more than coping with disasters: Implications for health care policy. Schmalenbach Journal of Business Research. https://doi.org/10.1007/s41471-022-00132-0

Cotton, K., Booth Richard Booth, R. G., McMurray, J., & Treesh, R. (2022). Understanding health information exchange processes within Canadian long‐term care: A scoping review. International Journal of Older People Nursing. https://doi.org/10.1111/opn.12501

Fuller, A. E. C., Guirguis, L. M., Sadowski, C. A., & Makowsky, M. J. (2022). Evaluation of medication incidents in a long-term care facility using electronic medication administration records and barcode technology. The Senior Care Pharmacist, 37(9), 421–447. https://doi.org/10.4140/tcp.n.2022.421

Hsieh, M.-C., Chiang, P.-Y., Lee, Y.-C., Wang, E. M.-Y., Kung, W.-C., Hu, Y.-T., Huang, M.-S., & Hsieh, H.-C. (2021). An investigation of human errors in medication adverse event improvement priority using a hybrid approach. Healthcare, 9(4). https://doi.org/10.3390/healthcare9040442

Isaksson, S., Schwarz, A., Rusner, M., Nordström, S., & Källman, U. (2021). Monitoring preventable adverse events and near misses. Journal of Patient Safety, Publish Ahead of Print. https://doi.org/10.1097/pts.0000000000000921

Karnehed, S., Erlandsson, L.-K., & Norell Pejner, M. (2021). Nurses’ perspectives on an electronic medication administration record in home healthcare: Qualitative interview study (Preprint). JMIR Nursing, 5(1). https://doi.org/10.2196/35363

Laatikainen, O., Sneck, S., & Turpeinen, M. (2021). Medication-related adverse events in health care—what have we learned? A narrative overview of the current knowledge. European Journal of Clinical Pharmacology. https://doi.org/10.1007/s00228-021-03213-x

Nantsupawat, A., Poghosyan, L., Wichaikhum, O., Kunaviktikul, W., Fang, Y., Kueakomoldej, S., Thienthong, H., & Turale, S. (2021). Nurse staffing, missed care, quality of care and adverse events: A cross‐sectional study. Journal of Nursing Management, 30(2). https://doi.org/10.1111/jonm.13501

Pruitt, Z. M., Kazi, S., Weir, C., Taft, T., Busog, D.-N., Ratwani, R., & Hettinger, A. Z. (2023). A systematic review of quantitative methods for evaluating electronic medication administration record and bar-coded medication administration usability. Applied Clinical Informatics, 14(01), 185–198. https://doi.org/10.1055/s-0043-1761435

Raeissi, P., Aryankhesal, A., Shahidi Sadeghi, N., & Kalantari, H. (2022). Root Cause Analysis (RCA) of adverse events in one of the biggest western Iranian general hospitals: Short communication. Health Scope, 11(4). https://doi.org/10.5812/jhealthscope-118032

Raisi-Estabragh, Z., & Mamas, M. A. (2022). COVID-19: Health care implications. Cardiology Clinics. https://doi.org/10.1016/j.ccl.2022.03.010

Rigamonti, D., & Rigamonti, K. H. (2021). Achieving and maintaining safety in healthcare requires unwavering institutional and individual commitments. Cureus, 13(2). https://doi.org/10.7759/cureus.13192

Tanui, A. K. (2022). Ethical management of incidental findings related to development and use of digital health platforms for older people. www.theseus.fi. https://www.theseus.fi/handle/10024/785923

Detailed Assessment Instructions for the NURS FPX 6016 Adverse Event or Near-Miss Analysis Assessment

Write a comprehensive analysis (5-7 pages) of an adverse event or near miss from your nursing experience. Integrate research and data on the event to propose a quality improvement (QI) initiative to your current organization.

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.

This assessment’s goal is to address a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities with a quality improvement initiative to prevent future incidents.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• 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.
  • 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 similar adverse event or near miss.
• 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.
• Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
  • Communicate analysis and proposed initiative in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling.
  • Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.

Instructions

For this assessment, you will prepare a comprehensive analysis on an adverse event or near miss that you or a peer experienced during your professional nursing career. You will integrate research and data on the event and use this information as the basis for a quality improvement (QI) initiative proposal in your current organization.

The following points correspond to the grading criteria in the scoring guide. The subbullets under 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 relating 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 leading to the event.
   • Explain 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 the short- and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze each stakeholder’s contribution to the event.
   • Analyze the interprofessional team’s responsibilities and actions. Explain what measures each interprofessional team member should have taken to create a culture of safety.
   • 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 put in place to increase patient safety and prevent recurrence of the near miss or adverse event.
   • Determine the appropriateness of the technology application for a specific patient or situation.
   • Research scholarly, evidence-based literature to learn how institutions can integrate solutions to prevent similar events.
4. Incorporate relevant metrics of the adverse event or near-miss incident to support need for improvement.
   • Identify the salient data associated with the adverse event or near miss that is generated from the facility’s dashboard.
     • Note: Dashboard means data 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. Use resources such as the Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Institute for Healthcare Improvement (IHI), and the World Health Organization (WHO).
5. Outline a quality improvement initiative to prevent the recurrence of an adverse event or near miss.
   • Explain, from an evidence-based viewpoint, how your facility now manages or should manage the process or protocol.
   • Evaluate how other institutions addressed similar incidents or events.
   • Analyze QI initiatives developed to prevent similar incidents. Explain why they are successful. Provide evidence of their success.
   • Propose solutions for your selected institution that can be implemented to prevent similar future adverse events or near-miss incidents.
6. Communicate analysis and proposed initiative in a professional, 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 APA style.

Example Assessment: You may use the Adverse Event or Near-Miss Analysis Exemplar [PDF] for an idea of what an assessment receiving a proficient or higher evaluation would look like.

Additional Requirements

• Submission length: 5–7 typed, double-spaced pages.
• Font: Times New Roman, 12 points.
• Number of references: Cite a minimum of 5 current scholarly and/or authoritative sources to support your evaluation, recommendations, and plans. Current literature is defined as no older than 5 years unless it is a seminal work.
• APA formatting: Citations and references must adhere to APA style and formatting guidelines. Consult these resources for an APA refresher:
  • APA Style & Format.
  • APA Module.
  • American Psychological Association. (n.d.). APA style. Retrieved from https://www.apastyle.org/

Grading Rubric: 

1. Analyze the missed steps or protocol deviations related to an adverse event or near miss.

Passing Grade:  Analyzes the missed steps or protocol deviations related to an adverse event or near miss. Identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty where further information could improve the analysis. 

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

Passing Grade:  Analyzes the implications of the adverse event or near miss for all stakeholders. Identifies assumptions on which the analysis is based. 

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

Passing Grade:  Evaluates quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Identifies criteria by which to evaluate the technologies. 

4.   Incorporate relevant metrics of the adverse event or near-miss incident to support need for improvement.

Passing Grade:  Incorporates relevant metrics of the adverse event or near-miss incident to support need for improvement. Evaluates the quality of the data. 

5.  Outline an evidence-based quality improvement initiative to prevent an adverse event or near miss.

Passing Grade:  Outlines an evidence-based quality improvement initiative to prevent an adverse event or near miss. Impartially considers conflicting data and other perspectives. 

6.   Communicate analysis and proposed initiative in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling.

Passing Grade:  Communicates analysis and proposed initiative in a professional, effective, and error-free manner, writing clearly and logically. 

7.   Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.

Passing Grade:  Integrates relevant sources to support arguments, formatting citations and references, using APA style without errors. 

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