Assessment 1: Adverse Event or Near-Miss Analysis

Assessment 1: Adverse Event or Near-Miss Analysis

Assessment 1: Adverse Event or Near-Miss Analysis

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.

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.

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.

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.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

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• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. Assessment 1: Adverse Event or Near-Miss Analysis

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. Assessment 1: Adverse Event or Near-Miss Analysis

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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