Adverse Event or Near Miss Analysis
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.
1. Analyze the missed steps or protocol deviations related to an adverse event or near miss.
o Describe how the event resulted from a patient’s medical management rather than from the underlying condition.
o Identify and evaluate the missed steps or protocol deviations that led to the event.
o Discuss the extent to which the incident was preventable.
o Research the impact of the same type of adverse event or near miss in other facilities.
Analyze the implications of the adverse event or near miss for all stakeholders.
o 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.
o Analyze the responsibilities and actions of the interprofessional team. Explain what measures should have been taken and identify the responsible parties or roles.
o Describe any change to process or protocol implemented after the incident.
Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
o Analyze the quality improvement technologies that were put in place to increase patient safety and prevent a repeat of similar events.
o Determine whether the technologies are being utilized appropriately.
o Explore how other institutions integrated solutions to prevent these types of events.
Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.
o 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.)
o Analyze what the relevant metrics show.
o 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.
Outline a quality improvement initiative to prevent a future adverse event or near miss.
o Explain how the process or protocol is now managed and monitored in your facility.
o Evaluate how other institutions addressed similar incidents or events.
o Analyze QI initiatives developed to prevent similar incidents, and explain why they are successful. Provide evidence of their success.
o Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.
Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.