Overview

Write a 5–7-page a comprehensive analysis on an adverse event or near miss from your professional nursing experience. Integrate research and data on the event and use as a basis to propose a quality improvement (QI) initiative in your current organization.

Health care organizations strive for a culture of safety. Yet despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation and regulations, medical errors continue to occur. 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.

The goal of this assessment is to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a quality improvement initiative to prevent future incidents.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment 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.
• Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
  • 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 future 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 and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
  • Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

Competency Map

Check Your ProgressUse this online tool to track your performance and progress through your course.

Assessment Instructions

Preparation

Prepare a comprehensive analysis on an adverse event or near-miss from your professional nursing experience that you or a peer experienced. Integrate research and data on the event and use as a basis to propose a Quality Improvement (QI) initiative in your current organization.

Note: Remember, you can submit all, or a portion of, your draft to Smarthinking for feedback, before you submit the final version of your analysis for this assessment. However, be mindful of the turnaround time for receiving feedback, if you plan on using this free service.

The numbered points below correspond to grading criteria in the scoring guide. The bullets below 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 that relate 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 that led to the event.
   • Discuss 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 both short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze how it was managed and who was involved.
   • Analyze the responsibilities and actions of the interprofessional team. Explain what measures should have been taken and identify the responsible parties or roles.
   • 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 that were put in place to increase patient safety and prevent a repeat of similar events.
   • Determine whether the technologies are being utilized appropriately.
   • Explore how other institutions integrated solutions to prevent these types of events.
4. Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.
   • Identify the salient data that is associated with the adverse event or near miss that is generated from the facility’s dashboard. (By dashboard, we mean the data that is 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.
5. Outline a quality improvement initiative to prevent a future adverse event or near miss.
   • Explain how the process or protocol is now managed and monitored in your facility.
   • Evaluate how other institutions addressed similar incidents or events.
   • Analyze QI initiatives developed to prevent similar incidents, and explain why they are successful. Provide evidence of their success.
   • Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.
6. Communicate analysis and proposed initiative in a professional and 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 current APA style.

Submission Requirements

• Length of submission: A minimum of five but no more than seven double-spaced, typed pages.
• Number of references: Cite a minimum of three sources (no older than seven years, unless seminal work) of scholarly or professional evidence that support your evaluation, recommendations, and plans.
• APA formatting: Resources and citations are formatted according to current APA style and formatting.

Note: Faculty may use the Writing Feedback Tool when grading this assessment. The Writing Feedback Tool is designed to provide you with guidance and resources to develop your writing based on five core skills. You will find writing feedback in the Scoring Guide for the assessment, once your work has been evaluated.

Adverse Event or Near Miss Analysis Scoring Guide

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• Develop a 2–5-page training strategies summary and annotated agenda for a training session that will prepare a role group to succeed in implementing your proposed organizational policy and practice guidelines.
  Training and educating those within an organization who are responsible for implementing and working with changes in organizational policy is a critical step in ensuring that prescribed changes have their intended benefit. A leader in a health care profession must be able to apply effective leadership, management, and educational strategies to ensure that colleagues and subordinates will be prepared to do the work that is asked of them.
• As a master’s-level health care practitioner, you may be asked to design training sessions to help ensure the smooth implementation of any number of initiatives in your health care setting. The ability to create an agenda that will ensure your training goals will be met, and will fit into the allotted time, is a valuable skill for preparing colleagues to be successful in their practice.
  Competency Map
  CHECK YOUR PROGRESSUse this online tool to track your performance and progress through your course.
• Assessment Instructions
• Note: Remember that you can submit all, or a portion of, your draft strategy summary and annotated training agenda to Smarthinking for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.
  To help ensure a smooth roll out and implementation of your proposed policy and practice guidelines, design a training session for one of the role groups in the organization that will be responsible for implementation.
  
  • Write a brief summary of your strategies for working with your chosen role group.
  • Explain how this training session will help prepare the group to succeed in implementing your proposed policy and practice guidelines, and why you chose this group to pilot your proposal.
  • Prepare an annotated agenda for a two-hour training session.
  • During this training session, you will want to ensure that the individuals you are training understand the new policy and practice guidelines. You will need them to buy into the importance of the policy in improving the quality of care or outcomes and their key role in successful policy implementation. You must help them acquire the knowledge and skills they need to be successful in implementing the policy and practice guidelines.
    As outcomes of this training session, participants are expected to:
  • Understand the organizational policy and practice guidelines to be implemented.
  • Understand the importance of the policy to improving quality or outcomes.
  • Understand that, as a group, they are key to successful implementation.
  • Possess the necessary knowledge and skills for successful implementation.
  • Requirements
    The strategy summary and annotated training agenda requirements outlined below correspond to the scoring guide criteria, so be sure to address each main point. Read the performance-level descriptions for each criterion to see how your work will be assessed. In addition, be sure to note the requirements for document format and length and for supporting evidence.
  • Summarize evidence-based strategies for working with the role group to obtain their buy-in and prepare them to implement the new policy and apply the associated practice guidelines to their work.
    • Why will these strategies be effective?
    • What measures might provide early indications of success?
  • Explain the impact of the new policy and practice guidelines.
    • How they will be implemented?
    • How will they affect the daily work routines and responsibilities of the role group?
  • Justify the importance of the new policy and practice guidelines with regard to improving the quality of care or outcomes related to the role group’s work.
    • How will the policy and guidelines help improve the quality of care or outcomes?
  • Explain the role group’s importance in implementing the new policy and practice guidelines.
    • Why is the work and buy-in of the role group important for successful implementation?
    • How could you help the group feel empowered by their involvement during implementation?
  • Determine appropriate and effective instructional content, learning activities, and materials for the training session.
    • How will each proposed activity on your agenda support learning and skill development?
    • Can you complete the training within the allotted two hours?
  • Organize content so ideas flow logically with smooth transitions.
    • Proofread your strategy summary and training agenda, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your strategies.
  • Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.
    • Be sure to apply correct APA formatting to source citations and references.
  • Example Assessment: You may use the Assessment 4 Example [PDF] to give you an idea of what a Proficient or higher rating on the scoring guide would look like.
    Strategy Summary and Training Agenda Format and Length
    Format your document using APA style.
  • Use the APA Style Paper Template [DOCX]. The APA Style Paper Tutorial [DOCX] will help you in writing and formatting your strategy summary and agenda. Be sure to include:
    • A title page and references page. An abstract is not required.
    • A running head on all pages.
    • Appropriate section headings.
  • Your strategy summary and agenda should be 2–5 pages in length, not including the title page and references page.
  • Supporting Evidence
    Cite 2–4 external sources to support your strategies for working with the group you have identified and generating their buy-in, as well as for your approach to the training session, activities, and materials.
    Note: Faculty may use the Writing Feedback Tool when grading this assessment. The Writing Feedback Tool is designed to provide you with guidance and resources to develop your writing based on five core skills. You will find writing feedback in the Scoring Guide for the assessment, once your work has been evaluated.
    Portfolio Prompt: You may choose to save your strategy summary and agenda to your ePortfolio.
    Competencies Measured
    By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
  • Competency 1: Analyze relevant health care laws, policies, and regulations; their application; and their effects on organizations, interprofessional teams, and professional practice.
    • Explain the impact of new policy and practice guidelines.
  • Competency 2: Lead the development and implementation of ethical and culturally sensitive policies that improve health outcomes for individuals, organizations, and populations.
    • Justify the importance of a new policy and practice guidelines with regard to improving the quality of care or outcomes related to a selected role group’s work.
    • Determine appropriate and effective instructional content, learning activities, and materials for a training session.
  • Competency 4: Develop strategies to work collaboratively with policy makers, stakeholders, and colleagues to address environmental (governmental and regulatory) forces.
    • Summarize evidence-based strategies for working with a selected role group to promote their buy-in and prepare them to implement a new policy and apply associated practice guidelines to their work.
    • Explain a selected role group’s importance in implementing a new policy and practice guidelines.
  • Competency 5: Produce clear, coherent, and professional written work, in accordance with Capella’s writing standards.
    • Organize content so ideas flow logically with smooth transitions.
    • Support main points, assertions, arguments, conclusions, or recommendations with relevant and credible evidence.

 

Evidence translation begins with the identification of a problem or concern. Reflect upon the eight national practice problems presented in the Global Burden of Disease Research. Select one of the practice problems to address the following.

1- From a global/nationwide perspective, how does the selected practice problem impact nurses, nursing care, healthcare organizations, and the quality of care being provided?

2- Identify the national level key stakeholders who are affected by the practice problem and stakeholders involved in resolution.

3-Are clinical practice guidelines used to address this problem? Why or why not? If used, provide a brief overview of the CPG. If a CPG is not used, propose an intervention that could be implemented on a national scale to address the problem.

  

Please answer these questions separated and use at least 3 sources no later than 5 years and you can use the sources below.

 

Please read the discussion question above carefully to answer all components.  Our resources available to support your learning and work in our discussions this week are:

·   Our Chamberlain Week 1 lesson: The Practice Problem: National Issues and Nonresearch Evidence
and Appraisal of Nonresearch Evidence and Stakeholder Roles

·  The Global Burden of Disease Research Links found in your week 1 student lesson plan- scroll down to access the links to this research!!

·         Dang and Dearholt (2018):  ·          

o             Chapter 1: Evidence-Based Practice: Context, Concerns, and Challenges

o             Chapter 7: Evidence Appraisal: Nonresearch

o             Appendix F: Nonresearch Evidence Appraisal Tool

White, Dudley-Brown, and Terhaar (2016): ·          

o             Chapter 4: Translation of Evidence to Improve Clinical Outcomes

Our interactive discussion addresses the following course outcomes:

·         Investigate practice problems relevant to advanced nursing practice. (POs 1, 3, 4, 5, 6, 9)

·         Appraise practice problems at the micro, meso, and macrosystems levels. (POs 2, 3, 4, 5, 6, 9)

·         Examine the role of stakeholders in change and translation science. (POs 1, 4, 6)

·         Assess challenges and barriers related to evidence translation. (POs 3, 5, 9)

Chamberlain College of Nursing. (2019). NR-701 Week 1: The Practice Problem: National Issues and Nonresearch Evidence [Online lesson]. Downers Grove, IL: Adtalem.

Dang, D., & Dearholt, S. L. (2018). Johns Hopkins nursing evidence-based practice: Model and guidelines (3rd ed.). Indianapolis, IN: Sigma Theta Tau International.

White, K. M., Dudley-Brown, S., & Terhaar, M. F. (2016). Translation of evidence into nursing and health care (2nd ed.). New York, NY: Springer Publishing Company.

 

• Morbidity and mortality, Years Lived with Disability (YLLS), QALYs (Quality-Adjusted Life Year) and DALYs (Disability-Adjusted Life Year) From the WHO:https://www.who.int/quantifying_ehimpacts/publications/en/9241546204chap3.pdf (Links to an external site.) 
• (2020). Health statistics and information systems. Retrieved from https://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/ (Links to an external site.)  
• (2020). Health statistics and information systems: Disability weights, discounting and age weighting of DALYs. Retrieved from https://www.who.int/healthinfo/global_burden_disease/daly_disability_weight/en/ (Links to an external site.)

Guides and tutorials on the Global Burden of Disease

The best resource to use to find incidence, prevalence, etc. by cause (or disease) is the GBD Results Tool: http://ghdx.healthdata.org/gbd-results-tool (Links to an external site.) (Links to an external site.)

This tool allows users to query our estimates from the latest round of the Global Burden of Disease study, GBD 2017. 

            – The GBD Results Tool User Guide: This contains help for common questions and

              troubleshooting

            – Codebook: This ZIP file contains a codebook file with the IDs AND names for all

               encoded values in the  tool, along with other useful documentation, such as a

               measure and metric definitions

            – Tools Overview: This file is a PDF guide to our data tools which also includes all

                variable names and  IDs, a glossary, and more

The GBD Results Tool includes estimates at the US state, but not county, level.

You can find our US county-level data collected on the US Data page here (may be older data): http://ghdx.healthdata.org/us-data (Links to an external site.) (Links to an external site.)

For more on searching the GHDx, please refer to the following resources:

   – Two brief introductory videos on browsing and searching the GHDx: http://ghdx.healthdata.org/help/ghdx-instructional-videos (Links to an external site.) (Links to an external site.)

    – More detailed search tips: http://ghdx.healthdata.org/help/searching-ghdx (Links to an external site.) (Links to an external site.)

Reference:

The U.S. Burden of Disease Collaborators. (2018). The state of U.S. health, 1990–2016 burden of diseases, injuries, and risk factors among U.S. states. JAMA, 319(14), 1444–1472. https://doi.org/10.1001/jama.2018.0158

1. You are going to present data that has been collected to your administrative group. The focus is on outcome measures and the data collected is unplanned readmission rates at two different hospitals. What format would you choose to display your data and why? What information would you include with the data?
   
2. Identify at least two stakeholder agency reporting sources. How do these external reporting groups contribute to or hinder CQI?
   
3. Select an effective current health policy that focuses on or affects population health. What components of this policy make it effective? Conduct research on its history and the factors that influenced its development

 As your EBP skills grow, you may be called upon to share your expertise with others. While EBP practice is often conducted with unique outcomes in mind, EBP practitioners who share their results can both add to the general body of knowledge and serve as an advocate for the application of EBP.

In this Discussion, you will explore strategies for disseminating EBP within your organization, community, or industry.

To Prepare:

• Review the Resources and reflect on the various strategies presented throughout the course that may be helpful in disseminating effective and widely cited EBP.
  • This may include unit-level or organizational-level presentations, poster presentations, and podium presentations at organizational, local, regional, state, and national levels, as well as publication in peer-reviewed journals.
• Reflect on which type of dissemination strategy you might use to communicate EBP.

Post at least two dissemination strategies you would be most inclined to use and explain why. Explain which dissemination strategies you would be least inclined to use and explain why. Identify at least two barriers you might encounter when using the dissemination strategies you are most inclined to use. Be specific and provide examples. Explain how you might overcome the barriers you identified.