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.
A comprehensive analysis on an adverse event or near miss that someone experienced during professional nursing career.
- 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.
- 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.
- 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.
- 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).
- Identify the salient data associated with the adverse event or near miss that is generated from the facility’s dashboard.
- 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.
Running head: ADVERSE EVENT OR NEAR-MISS ANALYSIS 1
Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.
Adverse Event or Near-Miss Analysis
Learner’s Name
Capella University
Quality Improvement for Interprofessional Care
Month, Year
Comment [JS1]: This submission is
very well crafted according to the
rubric. It is written in a scholarly
voice and free of APA and
grammatical errors.
ADVERSE EVENT OR NEAR-MISS ANALYSIS 2
Adverse Event or Near-Miss Analysis
Preventable adverse events are among the top causes of death in the United States.
Estimates reveal that 210,000 to 400,000 fatal adverse events occur every year (Allen, 2013).
Examples of preventable adverse events are hospital-acquired diseases, medication errors, and
patient falls. The focus of this adverse-event analysis is medication errors, also known as adverse
drug events (ADEs), such as medication overdoses or administration of wrong medicines. The
analysis will recommend strategies to mitigate ADEs based on a case of medication overdose
observed in the emergency department (ED) at TrueWill General Hospital (TGH), a
multispecialty hospital in the United States.
A 40-year-old woman was brought to the ED after suffering a seizure. Before she was
discharged, she suffered a second seizure and the ED doctor prescribed 800 mg of phenytoin, an
anti-seizure medication, to be given intravenously (IV). The ED nurse misread the prescribed
dosage in the electronic medical record (EMR) and administered 8000 mg, which was 10 times
greater than the prescribed dosage. The patient died soon after the lethal infusion (Manias, 2012).
The incident shows that the nurse made a series of cognitive errors in medication
management and missed key steps (Manias, 2012), which will be explained in the analysis
report. Additionally, the analysis will examine the implications of adverse events on multiple
stakeholders. Relevant evidence and metrics will be incorporated when making suggestions for
improvement of patient safety at TrueWill General Hospital.
Analysis of Missed Steps Related to the Adverse Event
Emergency departments are susceptible to adverse events because of the unscheduled
nature of patient presentation, urgency, and severity of cases. In such high-pressure situations,
Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.
ADVERSE EVENT OR NEAR-MISS ANALYSIS 3
clinicians must be more careful when treating a patient (Manias, 2012). Retracing the steps taken
by the nurse revealed several missed steps in th
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Stephanie Johnson
Capella Uni