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

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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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Sandra Lewis  

Re: Topic 5 DQ 2
The Baby-Friendly Hospital Initiative (BFHI) is a global initiative of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), (PH, 2019). Their aim is to improve health outcomes for mothers and babies through breastfeeding and immediate skin-to-skin bonding. Through successful implementation of the integration of technology BFHI has the power to help transform the way breastfeeding care and educations are delivered. Health Information Technology (HIT) is used to record, analyze, and share patient health data. HIT is also able to utilize personal health tools including smart devices and apps to help educate and inform the healthcare team as well as the mothers. This technology is able to remind mothers when to feed, help set schedules, reinforce education on diapering and hunger cues, assist in education on fussy babies, proper diets for breastfeeding mothers and help to keep logs on last feeding, length of time spent on breast and remind busy mothers which breast was last fed on. The purpose of HIT is to provide better care for patients and help achieve health equity. HIT supports recording of the patients’ data to improve healthcare delivery and allow for analysis of this information for both healthcare practitioners and government agencies, (OMRS, 2019). By implementing this data can assist the healthcare team on identifying issues that the mother may need support on. HIT such as IPad’s and virtual reality training with real case scenarios will also allow for policies and procedure to be quickly identified along with sources of EBP’s that can help to facilitate the implementation of BFHI.Open MRS, (2019). “The Importance of Health Information Technology in Developing Areas.” Retrieved from https://openmrs.org/2017/07/the-importance-of-health-information-technology-in-developing-areas/Prisma Health, (2019). “Baby Friendly Hospital.” Retrieved from https://www.palmettohealth.org/medical-services/womens-services/birthplace/baby-friendly-hospital