Adverse Event or Near Miss Analysis
This document is designed to give you questions to consider and additional guidance to help you successfully complete the Adverse Event or Near Miss Analysis assessment. You may find it useful to use this document as a prewriting exercise, an outlining tool, or a final check to ensure you have sufficiently addressed all the grading criteria for this assessment. This document is a resource to help you complete the assessment.
Do not turn in this document as your assessment submission.
For examples of adverse events or near misses, visit:
Agency for Healthcare Research and Quality. (2021).
WebM&M cases & commentaries
Analyze the implications of the adverse event or near miss for all stakeholders.
· What are the possible short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community, et cetera)?
· What are the responsibilities and actions of the interprofessional team related to the adverse event or near miss?
· What measures should have been taken? Who are the responsible parties or roles?
· How did the incident impact the stakeholders? Did it change how they do their work, or how or what they report?
Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.
· How did the event result from a patient’s medical management rather than from the underlying condition?
· What were the missed steps or protocol deviations that led to the adverse event or near miss? What was overlooked? Why?
· What kind of interprofessional communications could have prevented this event?
· To what extent was the adverse event or near miss preventable?
Evaluate quality improvement actions or technologies related to the event that are required to reduce risk and increase patient safety.
· What quality improvement technologies are in place to increase patient safety and reduce risks that pertain to this adverse event? What would prevent it from happening in the future?
· Are those technologies being utilized appropriately? How could they be more usefully employed?
· How do other institutions prevent these types of events from occurring?
· What data are generated from the facility’s dashboard related to the selected incident? (By dashboard, we mean the data that are generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management. This is not something you will find online.)
· What data are associated with the adverse event or near miss? What do the relevant metrics show? (Patient satisfaction and readmission rates are important metrics. Look at trending data and compare to see where relevant metrics are headed.)
· What research or data related to the adverse event or near miss is available outside of your institutPrepare 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
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