Assessment 1 Instructions: Adverse Event or Near-Miss Analysis... 08/08/2023, 18:01

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Assessment 1 Instructions: Adverse Event or Near-Miss

Analysis

Prepare an analysis (5-7 pages) of an adverse event or a near miss from your professional nursing experience and

outline a QI initiative that would address it.

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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.

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The goal of this assessment is to allow you to focus on a specific event in a health care setting that impacts

patient safety and related organizational vulnerabilities and to propose a QI initiative to prevent future incidents.

It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself

in as a health care professional.

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.

Historically, medical errors were reported and analyzed in hindsight. Today, QI initiatives attempt to be

proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by

new technologies and reporting metrics, adverse events and near misses can provide insight into potential ways

to improve care delivery and ensure patient safety.

For clarification, the National Quality Forum (n.d.) defines the following:

Adverse event: An event that results in unintended harm to the patient by an act of commission or

omission rather than by the underlying disease or condition of the patient.

Near miss: An event or a situation that did not produce patient harm, but only because of intervening

factors, such as patient health or timely intervention.

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Prepare a comprehensive analysis of an adverse event or a near miss from your professional nursing experience

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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.

Be sure your analysis addresses all of the above points. You may also want to read the Adverse Event or Near

Miss Analysis Scoring Guide to better understand the performance levels that relate to each grading criterion.

Additionally, be sure to review the Guiding Questions: Adverse Event or Near Miss Analysis [DOCX] document

for additional clarification about things to consider when creating your assessment.

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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. Review the Nursing Master's Program (MSN) Library Guide for

guidance.

APA formatting: Resources and citations are formatted according to current APA style. Review the

Evidence and APA section of the Writing Center for guidance.

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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

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interprofessional care.

Convey purpose, in an appropriate tone and style, incorporating supporting evidence and

adhering to organizational, professional, and scholarly writing standards.

Reference

National Quality Forum. (n.d.). NQF patient safety terms and definitions.

http://www.qualityforum.org/Topics/Safety_Definitions.aspx

SCORING GUIDE

Use the scoring guide to understand how your assessment will be evaluated.

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VIEW SCORING GUIDE

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