OverviewWrite 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.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.The goal of this assessment is to
focus on a specific event in a health care setting that impacts
patient safety and related organizational vulnerabilities and to
propose a quality improvement initiative to prevent future
incidents.By successfully completing this assessment, you will
demonstrate your proficiency in the following course competencies
and assessment criteria:Competency 1: Plan quality improvement
initiatives in response to adverse events and near-miss
analyses.Evaluate quality improvement technologies related to the
event that are required to reduce risk and increase patient
safety.Competency 2: Plan quality improvement initiatives in
response to routine data surveillance.Analyze the missed steps or
protocol deviations related to an adverse event or near
miss.Analyze the implications of the adverse event or near miss for
all stakeholders.Outline a quality improvement initiative to
prevent a future adverse event or near miss.Competency 3: Evaluate
quality improvement initiatives using sensitive and sound outcome
measures.Incorporate relevant metrics of the adverse event or near
miss incident to support need for improvement.Competency 5: Apply
effective communication strategies to promote quality improvement
of interprofessional care.Communicate analysis and proposed
initiative in a professional and effective manner, writing content
clearly and logically with correct use of grammar, punctuation, and
spelling.Integrate relevant sources to support arguments, correctly
formatting citations and references using current APA
style.Competency MapCheck Your ProgressUse this online tool to
track your performance and progress through your course.Assessment
InstructionsPreparationPrepare 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.Integrate relevant sources to support arguments, correctly
formatting citations and references using current APA
style.Submission RequirementsLength 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.Note: Faculty may use theWriting
Feedback Toolwhen grading this assessment. The Writing Feedback
Tool is designed to provide you with guidance and resources to
develop your writing based on five core skills. You will find
writing feedback in the Scoring Guide for the assessment, once your
work has been evaluated.Adverse Event or Near Miss Analysis Scoring
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