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Write a comprehensive analysis of an adverse event or near mess from your nursing experience. Integrate research and data on the event to propose a quality improvement initiative to your current organization.
Introduction: healthcare 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 and aware 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 a tributable to ineffective interprofessional communication. This assessment goal is to address a specific event in a healthcare 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 mess that you or appear experience during your professional nursing career. You will integrate research and data on the event and use this information as a basis for quality improvement initiative proposal in your current organization. The following points correspond to the grading criteria in the scoring guide. The sub bullets 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 related to each grading criterion.
1. Analyze the missteps or protocol deviations related to an adverse event or near mess describe how the event resulted from a patient’s medical management rather than from the underlying condition, identify and evaluate the missteps 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 mess for all stakeholders. Doing this, you’ll need to evaluate the short and long-term effects on the stakeholders, the patients, the family, interprofessional team, facility, and community. Analyze each stakeholder his contribution to the event. Analyze the interprofessional teams responsibilities and actions. Explain what measures each interprofessional team member should have taken to create a culture of safety. Describe any changes 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 reoccurrence of the near mess or adverse event. Determine the appropriateness of the technology application for a specific patient or situation. Research a scholarly evidence-based literature to learn how institutions can integrate solution 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 mess that is generated from the facilities dashboard. Note: dashboard means data generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for healthcare management. Analyze what the relevant metrics show. Explain research or data related to the adverse event or near mess that is available outside of your institution. Compare internal data to external data. Use resources such as centers for disease control and prevention CDC, agency for healthcare research and quality AHRQ, Institute for health improvement IHI, and the world health organization WHO.
5. Outline of quality improvement initiative to prevent the reoccurrence of an adverse event or near mess. Explain, from an evidence-based viewpoint, your facility now manages or should manage the process or protocol. Evaluate how other institutions address similar incidents or events. Analyze QI initiatives develop 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 mess incidents.
6. Communicate analysis and propose initiative in a professional, effective manner, writing contact clearly and logically with correct use of grammar, punctuation, and spelling. Integrate relevant sources that are ideally less than five years old.
1. Analyze the missed steps or protocol deviations related to an adverse event or near mess. Identify knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty where further information could improve the analysis.
2. Analyze the implications of the adverse event or near mess for all stakeholders. Identify assumptions on which the analysis is based.
3. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Identify criteria by which to evaluate the technologies.
4. Incorporate relevant metrics of the adverse event or near mess incident to support need for improvement. Evaluate the quality of the data.
5. Outline and evidence-based quality improvement initiative to prevent an adverse event or near miss. Imp partially consider conflicting data and other perspectives.
6. Communicate analysis and proposed initiative in a professional, effective, and air free manner, Reading clearly and logically.
7. Integrate relevant sources to support arguments, formatting citations and references, try to use references that are within five years, use APA style without errors.

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