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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.
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.
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.
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.
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.
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.
Reference
National Quality Forum. (n.d.). NQF patient safety terms and definitions. http://www.qualityforum.org/Topics/Safety_Definitions.aspx
INSTRUCTOR FEEDBACK
Competency 1
Plan quality improvement initiatives in response to adverse events and near-miss analyses.
Criterion
Analyze the implications of an adverse event or a near miss for all stakeholders.
Your Result:PROFICIENT
Analyzes the implications of an adverse event or a near miss for all stakeholders.
Faculty Comments:You
did a nice job analyzing the missed steps (or protocol deviations) related to an adverse event or near miss. To move this to a distinguished level, you needed to identify the assumptions or rationale
for your analysis. Consider including support from current literature. NON_PERFORMANCE
Does not list the implications of an adverse event or a near miss for all stakeholders.
BASIC
Lists
possible impacts of an adverse event or a near miss for stakeholders, but fails to analyze their short- or long-term implications for the stakeholders.
Your Result:PROFICIENT
Analyzes the implications of an adverse event or a near miss for all stakeholders.
DISTINGUISHED
Analyzes
the implications of an adverse event or a near miss for all stakeholders, and identifies assumptions on which the analysis is based.
Criterion
Analyze
the sequence of events, missed steps, or protocol deviations related to
an adverse event or a near miss using a root cause analysis.
Your Result:PROFICIENT
Analyzes
the sequence of events, missed steps, or protocol deviations related to
an adverse event or a near miss using a root cause analysis.
Faculty Comments:You
did a nice job analyzing the missed steps (or protocol deviations) related to an adverse event or near miss. To move this to a distinguished level, you needed to identify knowledge gaps where further
information could improve your analysis. In addition, consider inclusing support from current literature. NON_PERFORMANCE
Does not list the missed
steps or protocol deviations
related to an adverse event
or a near miss.
BASIC
Lists the missed steps or
protocol deviations related to an
adverse event or a near miss, but
fails to analyze how they led to
the adverse event or near miss.
Your Result:PROFICIENT
Analyzes
the sequence of events, missed steps, or protocol deviations related to
an adverse event or a near miss using a root cause analysis.
DISTINGUISHED
Analyzes
the sequence of events, missed steps, or protocol deviations related to
an adverse event or a near miss using a root cause analysis, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the analysis).
Criterion
Outline
a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.
Your Result:DISTINGUISHED
Outlines
a quality improvement initiative to prevent a future adverse event or near miss, and impartially considers conflicting data and other perspectives.
Faculty Comments:Great
work outlining a quality improvement initiative to prevent a future adverse event or near miss. You impartially considered conflicting data and other perspectives.
NON_PERFORMANCE
Does not outline a quality improvement initiative to prevent a future adverse event or near miss.
BASIC
Attempts
to outline a quality improvement initiative to prevent a future adverse
event or near miss, but it is not clear that quality improvement suggestions are based on research or best practices.
PROFICIENT
Outlines
a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.
Your Result:DISTINGUISHED
Outlines
a quality improvement initiative to prevent a future adverse event or near miss, and impartially considers conflicting data and other perspectives.
Competency 3
Evaluate quality improvement initiatives using sensitive and sound outcome measures.
Criterion
Evaluate
and identify quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.
Your Result:PROFICIENT
Evaluates and identifies quality
improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.
Faculty Comments:Good
work on this section! You evaluated quality improvement technologies related to the event that are required to reduce risk and increase patient safety. To move this to a distinguished grade, you needed to include support from literature. Competency 5
Apply effective communication strategies to promote quality improvement of interprofessional care.
Criterion
Convey
purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.
Your Result:BASIC
Conveys
purpose, in an appropriate tone or style. Clear, effective communication is inhibited by insufficient supporting evidence and/or minimal adherence to applicable writing standards.
Faculty Comments:There
were many APA inconsistencies noted on your paper (title page, headers,
page numbers, headings, in-text citations, references). I hope you will
reach out to your tutor, who has wonderful resources to help you with APA. The supplemental resources link on the course room homepage is also a helpful resource. In addition, here’s a link to APA formatting that may be helpful: http://www.apastyle.org/learn/tutorials/basics-tutorial.aspx
In addition, some of you sources are outdated. Be sure to use current scholarly literature to support your assessment. NON_PERFORMANCE
Does
not convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and writing scholarly standards.
Your Result:BASIC
Conveys
purpose, in an appropriate tone or style. Clear, effective communication is inhibited by insufficient supporting evidence and/or minimal adherence to applicable writing standards.
PROFICIENT
Conveys
purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.
DISTINGUISHED
Conveys
clear purpose, in a tone and style well-suited to the intended audience. Supports assertions, arguments, and conclusions with relevant,
credible, and convincing evidence. Exhibits strict and nearly flawless adherence to organizational, professional, and scholarly writing standards, including APA style and formatting.