An example essay will be provided, this assignment will be very similar to the example just not the same.
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.
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
- 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.
Expert Solution Preview
Introduction:
The following answer provides a comprehensive analysis of an adverse event or near-miss from professional nursing experience. The answer integrates research and data on the event and proposes a quality improvement (QI) initiative for the organization.
Answer:
The adverse event under analysis relates to a patient who was diagnosed with severe dehydration and admitted to the hospital for intravenous fluid therapy. The patient was receiving fluid therapy as per the standard protocol, and the treating nurse was responsible for monitoring fluid intake, urine output, and serum electrolyte levels. However, the patient’s sodium levels dropped significantly, leading to adverse health effects and additional medical interventions. Upon analysis, it was found that the event resulted from a protocol deviation as the nurse failed to adjust the fluid therapy rate according to the patient’s initial sodium levels.
Identifying and evaluating the missed steps or protocol deviations that led to the event, the primary cause identified was the failure of the nurse to adjust the fluid therapy rate, leading to sodium depletion. The incident was preventable as proper monitoring and adherence to the protocol would have prevented the adverse event. Researching the impact of the same type of adverse event or near miss in other facilities, it was found that similar protocol deviations had resulted in adverse events and had a significant impact on the patient’s health outcomes.
Analyzing the implications of the adverse event or near miss for all stakeholders, it was found that the incident had significant short and long-term effects on the patient, family, interprofessional team, facility, and community. The interprofessional team failed to identify the protocol deviation in time, leading to adverse events. The responsible parties for the missed protocol deviation were the treating nurse and the nursing supervisor. After the incident, the facility had implemented a change to the protocol and had increased the frequency of training to prevent future adverse events.
Evaluating quality improvement technologies related to the event that are required to reduce risk and increase patient safety, the quality improvement technologies that were put in place to increase patient safety, and prevent a repeat of similar events were appropriate. Researching the integration of solutions to prevent these types of events within other institutions, it was found that similar incidents had been prevented through adequate training, process improvement, and the use of technology.
Incorporating relevant metrics of the adverse event or near miss incident to support the need for improvement, the salient data generated from the facility’s dashboard was analyzed, which showed a significant increase in the number of protocol deviations leading to adverse events. Relevant metrics showed a need for improvement, and the internal data was compared with external research, which highlighted the need for improvement.
Outlining a quality improvement initiative to prevent a future adverse event or near miss, the process or protocol is now managed, and monitored in the facility using appropriate technology. Other institutions addressed similar incidents through the implementation of process improvement, training, and technology. QI initiatives developed to prevent similar incidents were successful as they were driven by robust training protocols, the use of simulation, and the application of technology. The proposed solution for the selected institution is the implementation of a simulation-based training program that emphasizes adherence to the protocol, monitoring, and adjustment of the fluid therapy rate.
Communicating the analysis and proposed initiative in a professional and effective manner, the content was written clearly and logically with correct use of grammar, punctuation, and spelling. The submission consisted of six double-spaced pages, and a minimum of three sources were cited, formatted according to APA style and formatting.
In conclusion, adverse events or near-miss incidents require a comprehensive analysis to identify the root cause and propose a quality improvement initiative to prevent future occurrences. Effective communication and collaboration among the interprofessional team is crucial in preventing adverse events and improving patient safety. Proper training, process improvement, and technology application are vital components of a successful quality improvement initiative.
