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.

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.

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
7. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

Submission Requirements

• 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.

CONTEXT:

The purpose of the report is to assess whether specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Nurses and other health professionals with specializations and/or interest in the condition, disease, or the selected issue are your target audience.

Adverse Event or Near Miss Analysis

QUESTIONS TO CONSIDER:

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

Reflect on quality improvement (QI) initiatives in your workplace:

• What makes a QI initiative a success? What elements must be incorporated?
• What opportunities are there for interprofessional collaboration on a QI initiative in your workplace?
• Proficiency in interpretation of data is critical to understanding and communicating QI outcome measures. What can be done to improve data literacy across interprofessional teams?

SAMPLE ANSWER

Adverse Event or Near Miss Analysis

Introduction

Adverse events are defined as injuries resulting in unnecessary and prolonged hospitalization, disability or even death as a result of healthcare mismanagement. On the other hand, a near miss is a serious error that could potentially result in an adverse event, but fails to do so due to an intervention or by chance (Rafter et al., 2015). These events have a significant impact on patients and result in increased healthcare costs attributed to longer stays in the hospital. Preventable medical errors are not limited to lower quality healthcare facilities; excellent facilities also experience undesirable events. What differentiates high quality facilities from low quality facilities is the way they respond to adverse events to significantly reduce the risk of the event reoccurring. Research shows that approximately 10% of patients will experience preventable harm during their stay in a medical facility. Over the years, health systems and governments have invested heavily in quality improvement systems to reduce harm to patients (Harrison et al., 2019). Additionally, incident reporting and analysis of adverse and near miss events plays a critical role in reducing and preventing reoccurrence.

Adverse Event or Near Miss Analysis

As a nurse who offers care to elderly patients over 70 years old, there are several adverse events that affect patient care and result in harm. Falls are a devastating and common complication in healthcare facilities particularly for older patients. Statistics shows that between 700,000 to 1 million hospitalized patients fall every year. A large percentage of patients who fall are in long-term care facilities (U.S Department of Health and Human Services, 2019). Furthermore, one-third of falls result in serious injuries including fractures, head traumas or even death. In line with this, the analysis will integrate research and data on falls, provide a real-life example in practice and recommend effective strategies to mitigate and prevent reoccurrence of falls in the healthcare facility.

The Adverse Event

The facility recently received a supply of modern mobility devices in form of walkers and canes. Among the elderly patients to benefit from the mobility devices was a 70-year old grandmother of four. All the beneficiaries of the devices received comprehensive training on how to use the walking aids. Additionally, the devices were fitted by professionals and every patient was assigned either a walker or a cane depending on the results of the professional assessment completed. The 70-year old grandmother was allocated a walker which was fitted to her unique needs taking into consideration the fact that she recently had a major hip surgery and required assistance to move around. However, during a shift change, there was poor communication between nurses and as a result, the patient was given a cane instead. The patient within a few minutes of using the cane, fell and broke her hip and pelvis. She was immediately rushed to the emergency room.

Analysis of Missed Steps Related to the Adverse Event

Research shows that over 47,000 emergency room visits for falls are related to the use of canes and walkers in individuals over 65 years old. Generally, older people using walking aids are at a higher risk of falling than those who do not use walking aids. This is attributed to spatiotemporal gait pattern, age and psychotropic drug intake. Therefore, extensive training and the use of appropriate walking aids greatly reduces occurrence of falls (de Mettelinge& Dirk, 2015). In addition to the high-risk factors associated with elderly falls, nurse errors played a critical role in the 70-year old grandmother’s fall-related injuries.

Adverse Event or Near Miss Analysis

Clinical handovers occur in clinical settings between shifts. During these processes, professional responsibility over a patient is transferred from one healthcare professional to another, either on a temporary basis or permanently (Manias et al., 2015). The transfer of essential information is an integral part of communication in the healthcare setting. Ineffective handoffs such as the one experienced in the facility result in breaches in patient safety, which ultimately results in serious harm. There was a communication breakdown during the clinical handoff of the patient resulting in them receiving a cane rather than a walker. Since the mobility devices were new in the facility, there was little to no information about their use. Apart from the training given to patients by professionals, nurses were never trained on the appropriate use of these devices. Ineffective patient handoff and lack of staff training resulted in the patient’s fall and required emergency care.

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While mobility devices have been known to reduce falls, other studies have questioned their efficacy. These studies claim that individuals who use mobility devices like canes or walkers may already have a predisposition to falls. Therefore, the number of falls that have been prevented by mobility devices cannot be correctly determined (Gell et al. 2016).

Implications of the Adverse Event for all Stakeholders

Patient safety as a healthcare discipline aims to prevent and reduce healthcare risks that occur to patients in healthcare facilities. Adverse events have a negative effect on patient safety and the quality of care they receive. When these events occur, patients are the most affected.Patient families are also affected when adverse events occur. In addition to patients and their families, healthcare facilities, care givers and the community experience both short and long-term effects of adverse events.When patients visit a healthcare facility, they generally expect that the care they receive will have a positive impact on their health and not worsen it (Schwendimann et al.,2018). To analyze the effect of adverse events on patients, their families, the healthcare facility and the community in general, several assumptions are made; stakeholders have a critical role to play in ensuring quality care is provided. The organization’s culture affects quality of care offered to patients and effective communication between care givers reduces the occurrence of adverse events.

The first victims of adverse events are patients and their families. When medical errors occur, patients risk experiencing life-changing events including; disability, extended hospital stays, physical harm or even death. Additionally, patients and their families experience psychological harm brought about by grief and avoidable patient suffering. Disability and death also result in economic stress on family members and caregivers (Holden & Card, 2019).

Healthcare professionals experience emotional distress following adverse events. Referred to as the second victims, healthcare professionals experience feelings of guilt, shame, fear, anger, disappointment and doubt when the patients they are caring for experience adverse events. Studies show that these feelings are long lasting and affect their future interactions with patients. Additionally, physicians report loss of self-confidence, increased anxiety about future errors and reduced job satisfaction (Ullstrom et al. 2014)

Evaluation of Quality Improvement Technologies

Communication patterns during shift transfers are ambiguous, problematic and non-standardized, thus contributing to increased patient harm. Attention should be focused on improving communication during patient handover. The use of standardized communication aids like the situation, background, assessment, recommendation (SBAR) tool improve communication between health care professionals (Gobel et al., 2014). When caregivers communicate with SBAR forms, two cue types of communication should be evaluated. They include; patient-situation cues that convey patient’s situation and background cues that convey specific data about the patient’s situation. Successful use of SBAR involves effective use of both cues without any data omissions (Gobel et al. 2014). Other communication devices like iSoBar checklist and TeamStepps team training tool significantly improve patient handover procedures and effectiveness. iSoBar handover forms are comprehensive and they reduce the number of clinical handover forms and prevent duplication of paperwork. They are easy to integrate into existing processes in the facility thus are well suited to local conditions.Likewise, the use of digital patient files and checklists in daily practice significantly reduce handover errors and incidences of miss-communication (Gobel et al., 2014).

Adverse Event or Near Miss Analysis

Healthcare facilities are increasingly using health information technology (HIT) to identify and prevent the occurrence of adverse events. Health information technology facilitates communication between healthcare providers, improves tracking and reporting of events and promotes quality of care by optimizing access to care and adhering to guidelines. HIT improves patient safety through the use of clinical flags, reminders and medication alerts (CommitteeOpinion, 2015).HITs can be evaluated by using a synthesis framework that analyses the rate of falls before and after its implementation. Success will be determined by the rate of reduced falls in the facility. Technology-based interventionsdetect falls as soon as they occur and alert clinicians. Technology also allows older adults to self-assess for assistive equipment provision (Hamm, Money, Atwal & Paraskevopoulos, 2016). Health information technology (HIT) improves patient care through the use of effective frameworks and metrics.

Relevant Metrics of the Adverse Event

The data on fall-related injuries will be obtained from electronic medical records used by clinicians to monitor patient’s treatments. Additionally, data will be retrieved from the patients’ electronic health records. Organizational departments including the administrative and finance department will provide supplemental data. Numerical data will be obtained from patient surveys that capture self-reported information from the elderly patients about their healthcare experiences. Additionally, patient numerical data will be obtained from the facility’s Minimum Data Set (MDS) and the Outcome and Assessment Information Set (OASIS). Three KPIs will be analyzed including; outcome, process and structural metrics. To maintain patient safety, the healthcare facility must use meaningful metrics. Effective frameworks are based on two main metrics: one that identifies measures and eliminates errors and the other that identifies measures and eliminates injuries (“Measurement of Patient Safety”, 2019). The data obtained from these metrics can be used to inform improvement efforts, enhance transparency and maintain organizational accreditation.

To prevent future falls, the facility should invest in safety measurement strategies. Among the most effective safety measurement strategies is the retrospective chart review which contains detailed clinical information. Voluntary reporting error systems are tools used for internal quality improvement and highlighting adverse events. Automated surveillance is a helpful tool used to screen patients who are at a higher risk of experiencing adverse eventssuch as falls.

AHRQ patient safety indicators are useful for tracking adverse events over a long period of time and across large groups of people. Lastly, the facility should rely on patient reports to capture communication errors between healthcare providers and other errors that are not easily recognized (“Measurement of Patient Safety”, 2019). While the aforementioned patient safety improvement frameworks will assist the facility reduce fall rates and improve patient handoff practices, there needs to be a quality improvement initiative to prevent future occurrence of the adverse event.

Quality Improvement Initiative to Prevent Future Adverse Event

Quality improvement (QI) is a formal approach designed to analyze practice performance and the efforts directed towards improving it. QI models present a formal framework for establishing quality processes in healthcare facilities. Among the common QI models is the model for improvement referred to as the plan-do-study-act (PDSA) cycle. This model combines the total quality management model and the rapid cycle improvement model (AHRQ, 2015). The “plan” stage requires the healthcare facility to write a concise statement of what it plans to test and what steps it will follow to execute the plan. The “do” stage requires the facility to execute the plan it established during the plan stage. After implementation, the facility should study the results to determine if the interventions implemented are successful. Lastly, the “act” stage requires the facility to analyze the overall outcomes of interventions to determine future implications (AHRQ, 2015).

Quality improvement initiatives designed to affect favorable change can use the PDSA model. The model is the most favorable model as it establishes a causal relationship between changes, behaviors and outcomes. In line with the proposed steps-, the facility should start with determining the scope of fall rates, what changes should be made, who should be involved, what KPIs should be measured and where the QI strategy will be targeted. To reduce fall rates in the facility, a multi-component quality improvement program that involves clinician education and prevention of falls should be implemented. There are several reasons that result in elderly falls. As such, educating nurses, clinicians and physiotherapists on adherence to protocols and general safety practices including proper use of walking aids will help prevent future falls. To further improve process outcomes, bi-annual training activities should be conducted especially before new devices like walking aids are introduced. Additionally, improving communication between nurses during patient handover and conducting comprehensive assessments will prevent future occurrence of preventable medical errors. The QI program designed should prompt primary care givers to implement interventions like referrals to other community resources and screening programs for patients with a high fall risk (Ganz et al. 2016). The screening programs should analyze predisposing factors like the use of medication such as anxiety and antipsychotic drugs and patients’ age. Likewise, the facility should incorporate the CDC STEADI (Stopping Elderly Accidents, Deaths and Injuries) initiative consisting of three core elements: Screen, assess, intervene. STEADI’s main goal is to reduce the risk of elderly falls by offering tailored interventions

Adverse Event or Near Miss Analysis

Measuring performance is essential to improving quality of healthcare. Effective QIs make use of available patient data. The PDSA model, when used in conjunction with health information technologies, will reduce the probability of future falls and improve communication between nurses, physicians and patients in the facility.

Conclusion

Man is to error. Healthcare providers are also human beings and therefore, at times, they make mistakeswhen administering care to their patients. Adverse events are very common in healthcare settings. As explained in the real-life scenario provided, elderly falls often result in life-threatening injuries. A majority of these falls are caused by inappropriate use of mobility devices. Poor communication practices between nurses during patient handovers also result in adverse events. However, by applying health information technologies and QI models, these errors can be controlled and prevented.

References

Committee Opinion. (2015). Patient safety and health information technology. The American College of Obstetricians and Gynecologists. Retrieved from https://m.acog.org/clinical-guidance-and-pub;ications/committee-opinions/

Gobel, B., Zwart, D., Hesselink, G. et al. (2014). Stakeholder perspectives on handovers between hospital staff and general practitioners: An evaluation through the microsystems lens. BMJ Quality & Safety, 1, 106-13. Doi:10.1136/bmjqs-2012-001192

Ganz, D.A. et al. (2016). The Effect of a Falls Quality Improvement Program on Serious Fall-related Injuries. Journal of the American Geriatrics Society, 63(1), 63-70. Doi: 10.1111/jgs.13154

Gell, N.M., Wallace, R.B. et al. (2016). Mobility Device Use Among Older Adults and Incidence of Falls and Worry About Falling: Findings from the 2011-2012 National Health and Aging Trends Study. Journal of the American Geriatrics Society, 63(5), 853-859. Doi: 10.1111/jgs.13393

Harrison, R., Sharma, A., Walton, M. et al. (2019). Responding to adverse patient safety events in Viet Nam. BMC Health Services Research, 19(677). Doi:10.1186/s12913-019-4518-y

Hamm, J., Money, A.G., Atwal, A. & Paraskevopoulos, I. (2016). Fall prevention intervention technologies: A conceptual framework and survey of the state of the art. Journal of Biomedical Informatics, 59, 319-345. Doi: 10.1016/j.jbi.2015.12.013th

“Health Literacy Universal Precautions Toolkit, 2^nd Edition”. (2015). Agency for Healthcare Research and Quality. Retrieved from https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool2b.html

Holden, J. & Card, A.J. (2019). Patient Safety Professionals as the Third Victims of Adverse Events. ResearchGate, 1-28. Doi: 10.1177/2516043519850914

De Mettelinge, R. & Dirk, C. (2015). Understanding the Relationship Between Walking Aids and Falls in Older Adults. Journal of Geriatric Physical Therapy, 38(3), 127-132. Doi: 10.1519/JPT.000000000000000000031

Manias, E., Geddes, F., Watson, B., Jones, D. & Della, P. (2015). Communication Failures During Clinical Handovers Lead to a Poor Patient Outcome: Lessons from a Case Report. Sage Open Medical Case Reports, 3. Doi: 10.1177/2050313X15584859

“Measurement of Patient Safety”. (2019). Agency for Healthcare Research and Quality, U.S Department of Health and Human Services, Retrieved from psnet.ahrq.gov/primer/measurement-patient-safety

Rafter, N., Hickey, A., Condell, S., Conroy, R., O’Connor, P., Vaughan, D. & Williams, D. (2015). Adverse Events in Healthcare: Learning from Mistakes. QMJ Monthly Journal of the Association of Physiciana, 108(4), 272-277. Doi: 10.1093/qjmed/hcu145.

Schwendimann, R. et al. (2018). The Occurrence, Types, Consequences and Preventability of in-Hospital Adverse Events- a Scoping Review. BMC Health Services Research, 18(521)

U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality (AHRQ) (2019). Falls. Retrieved from https://psnet.ahrq.gov/primer/falls

Ullstrom, S., Sachs, M.A., Hansson, J., Ovretveit, J. &Brommels, M. (2014). Suffering in Silence: A Qualitative Study of Second Victims of Adverse Events. BMJ Quality & Safety, 23(4). http://dx.doi.org/10.1136/bmjqs-2013-002035

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