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.


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.


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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

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,

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clinicians must be more careful when treating a patient (Manias, 2012). Retracing the steps taken

by the nurse revealed several missed steps in th