31 Mar Prepare an analysis (5-7 pages) of an adverse event or a near miss from your professional nursing experience and outline a QI initiative
Adverse event scenario: Patient began having reaction to blood transfusion. Orders for transfusion reaction included epinephrine IM (intramuscular). The bedside nurse administered the Epinephrine intravenously by mistake, not realizing the order said to be administered intramuscular. Patient began to feel physical symptoms such as chest pain from Intravenous epinephrine. EKG showed changes requiring cardiology evaluation to rule out heart attack caused by the epinephrine being administered intravenously.
Prepare a comprehensive analysis of an adverse event or a near miss from your professional nursing experience that you or a peer experienced. Provide an analysis of the impact of the same type of adverse event or near miss in other facilities. How was it managed, who was involved, and how was it resolved? Be sure to:
· Analyze the implications of the adverse event or near miss for all stakeholders.
· Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.
· Evaluate QI actions or technologies related to the event that are required to reduce risk and increase patient safety.
· Evaluate how other institutions integrated solutions to prevent these types of events.
· Incorporate relevant metrics of the adverse event or near miss to support need for improvement.
· Outline a QI initiative to prevent a future adverse event or near miss.
· Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards
Your assessment should also meet the following requirements:
· Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page or References section.
· Number of references: Cite a minimum of three sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work.
· Resources and citations are formatted according to current APA style
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
· Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.
· Analyze the implications of an adverse event or a near miss for all stakeholders.
· Analyze the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis.
· Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.
· Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
· Evaluate and identify quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.
· Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
· Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.
Guiding Questions
Adverse Event or Near Miss Analysis
This document is designed to give you questions to consider and additional guidance to help you successfully complete the Adverse Event or Near Miss Analysis assessment. You may find it useful to use this document as a prewriting exercise, an outlining tool, or a final check to ensure you have sufficiently addressed all the grading criteria for this assessment. This document is a resource to help you complete the assessment. Do not turn in this document as your assessment submission.
For examples of adverse events or near misses, visit:
Agency for Healthcare Research and Quality. (2021). WebM&M cases & commentaries . https://psnet.ahrq.gov/webmm
Analyze the implications of the adverse event or near miss for all stakeholders.
· What are the possible short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community, et cetera)?
· What are the responsibilities and actions of the interprofessional team related to the adverse event or near miss?
· What measures should have been taken? Who are the responsible parties or roles?
· How did the incident impact the stakeholders? Did it change how they do their work, or how or what they report?
Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.
· How did the event result from a patient’s medical management rather than from the underlying condition?
· What were the missed steps or protocol deviations that led to the adverse event or near miss? What was overlooked? Why?
· What kind of interprofessional communications could have prevented this event?
· To what extent was the adverse event or near miss preventable?
Evaluate quality improvement actions or technologies related to the event that are required to reduce risk and increase patient safety.
· What quality improvement technologies are in place to increase patient safety and reduce risks that pertain to this adverse event? What would prevent it from happening in the future?
· Are those technologies being utilized appropriately? How could they be more usefully employed?
· How do other institutions prevent these types of events from occurring?
· What data are generated from the facility’s dashboard related to the selected incident? (By dashboard, we mean the data that are generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management. This is not something you will find online or in the Capella library.)
· What data are associated with the adverse event or near miss? What do the relevant metrics show? (Patient satisfaction and readmission rates are important metrics. Look at trending data and compare to see where relevant metrics are headed.)
· What research or data related to the adverse event or near miss is available outside of your institution?
· Compare internal data to external data. What do you find?
Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.
· How was the incident managed and monitored in the selected institution?
· What quality improvement initiatives have been shown to work? Why are they successful? What is the evidence?
· What elements can be applied to prevent future adverse events or near misses?
Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.
· Is your analysis logically structured?
· Is your analysis 5–7 double-spaced pages (not including title page and reference list)?
· Is your writing clear and free from errors?
· Does your analysis include both a title page and reference list?
· Did you use a minimum of three sources? Were they published within the last five years?
· Are they cited in current APA format throughout the plan?
****NO USE OF AI. PLEASE USE APPROPRIATE APA IN TEXT CITATION****
