MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis
Sample Answer for MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis Included After Question
MSN 6016 Assessment 1 Adverse Event or Near Miss Analysis
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 inter-professional 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.
Running head: ADVERSE EVENT OR NEAR MISS ANALYSIS 1
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Adverse Event or Near Miss Analysis
Learner’s Name
Capella University
Quality Improvement for Interprofessional Care
Adverse Event or Near Miss Analysis
July, 2017
Comment [JS1]: This submission is
very well crafted according to the
rubric. The submission is written in a
scholarly voice and free of APA and
grammatical errors.
ADVERSE EVENT OR NEAR MISS ANALYSIS 2
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Adverse Event or Near Miss Analysis
Preventable adverse events are among the top causes of death in the United States.
Estimates reveal that 210,000 to 400,000 fatal adverse events occur every year (Allen, 2013).
Examples of preventable adverse events are hospital-acquired diseases, medication errors, and
patient falls. The focus of this adverse event analysis is medication errors, also known as adverse
drug events (ADEs), such as medication overdoses or administration of wrong medicines. The
analysis will recommend strategies to mitigate ADEs based on a case of medication overdose
observed in the emergency department (ED) at TrueWill General Hospital (TGH), a
multispecialty hospital in the United States.
A 40-year-old woman was brought to the ED after suffering a seizure. Before she was
discharged, she suffered another seizure and the ED doctor prescribed 800 mg of phenytoin, an
anti-seizure medication, to be given intravenously (IV). The ED nurse misread the prescribed
dosage in the electronic medical record (EMR) and administered 8000 mg, which was 10-fold
greater than the prescribed dosage. The patient died soon after the lethal infusion (Manias, 2012).
The incident shows that the nurse made a series of cognitive errors in medication
management and missed key steps (Manias, 2012), which will be explained in the analysis
report. Additionally, the analysis will examine the implications of adverse events on multiple
stakeholders. Relevant evidence and metrics will be incorporated when making suggestions for
improvement of patient safety at TrueWill General Hospital.
Analysis of Missed Steps Related to the Adverse Event
Emergency departments are susceptible to adverse events because of the unscheduled
nature of patient presentation, urgency, and severity of cases. In such high-pressure situations,
ADVERSE EVENT OR NEAR MISS ANALYSIS 3
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clinicians must be more careful when treating a patient (Manias, 2012). Retracing the steps taken
by the nurse revealed several missed steps in the delivery of care.
To begin with, the drug dispensing machines in the ED were stocked with phenytoin in
250 mg vials; the correct dose required only 3.2 vials. As the nurse had misread the dose, she
needed 32 vials of the drug. She took the vials from three different drug dispensers and
administered the dose using two IV bags as well as a piggyback line (Manias, 2012). The nurse
did not question the difficulty in procuring and administering the drugs; nor did she ask anyone
to validate her calculations. Furthermore, she was not asked why she was removing so many
vials from the drug dispensers in the ED unit.
The scenario also shows that the nurse was unaware of the toxic nature of phenytoin
when administered in large quantities; she was unable to recognize the warning signs.
Additionally, the fact that the nurse could remove 32 vials is evidence of the technical drawbacks
of the automated drug dispensing machines. The machines were not programed to send out alerts
when large quantities of medications, especially high-alert medication like phenytoin, were
dispensed (Manias, 2012). They were also not synced to the patient’s medical record. Therefore,
the machines contained no information on drug preparation or correct dosages and did not
display any warning signs.
Various systems factors such as communication, leadership, education, training, and
innovation of health care technology influenced the ED nurse’s clinical performance. The factors
originate from the adaptation of systems theory into health care (Huber, 2017). There are,
however, areas of uncertainty regarding the factors becoming problematic in TGH’s scenario. For
example, the nurse’s hesitation to consult her team could have been caused by staff management
problems such as conflict, overwork, or shortage of ED staff. Similarly, her lack of awareness of
ADVERSE EVENT OR NEAR MISS ANALYSIS 4
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dosages and safety measures shows gaps in education and training. Such problems are a result of
a breakdown of systems factors. Further evaluation is essential to understand the root causes of
adverse events and systems problems. Ignoring root causes can result in similar adverse events in
the future and negatively impact the stakeholders.
Implications of the Adverse Event on Stakeholders
Since medicine is a profession that depends on interpersonal relationships, adverse events
have unintended emotional, psychological, and professional consequences on all stakeholders.
Patients and their families are the first victims of adverse events, while health care professionals
and the organization become the second and third victims, respectively (Mira et al., 2015). A
similar inference can be made about the adverse event at TGH; the inference is supported by
certain assumptions about the health care environment. General assumptions about health care
are as follows: (a) quality health care is a result of positive relationships between all stakeholders
(Huber, 2017), (b) stakeholders are part of a high-risk environment where errors in clinical
practice are common, (c) health care professionals are not always responsible for errors as errors
are often caused by a breakdown in systems factors (Manias, 2012), and (d) errors diminish the
morale and job satisfaction of health care professionals and lead to more adverse events (Huber,
2017).
The analysis of implications on stakeholders begins with identifying how each category
of victims is impacted. The first victims expect hospital stays and procedures to be safe and
beneficial. When a patient suffers an injury, or dies because of medical negligence, the family
may feel aggrieved and may require counseling and support. They may feel unnerved and scared
by health care professionals (Bernhard, 2013) and hesitate to seek medical treatment in the
future. The study reported that health care professionals were traumatized after committing a
ADVERSE EVENT OR NEAR MISS ANALYSIS 5
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preventable error or witnessing an adverse event. They may lose confidence, abandon their
careers (Bernhard, 2013), and experience anxiety or depression (Mira et al., 2015). Adverse
events are damaging to careers, and nursing professionals may face difficulty in finding another
job (Bernhard, 2013).
Adverse events also affect the organization—the third victim—by damaging its
reputation. Adverse events can discourage people from seeking treatment at a particular hospital
(Mira et. al, 2015). Moreover, as most preventable errors are not covered by Medicaid and
Medicare services, the hospital can stand to lose a significant amount of reimbursement money.
It is important that health care organizations such as TGH find ways to minimize the
impact of adverse events on different stakeholders. The current trend in quality improvement
(QI) is focused on reducing human errors through automation of health care technologies. In the
case of TGH, the existing level of automation of patient records and drug dispensers is not
sufficient and needs to be replaced. The next section recommends and discusses the benefits of a
popular QI technology—patient care dashboards.
Evaluation of Quality Improvement Technologies
Performance measurement and reporting by health care professionals are the crux of QI
because transmitting, organizing, analyzing, and displaying performance data help in identifying
areas that need improvement (Ghazisaeidi, 2015). A recent development in QI technologies is the
introduction of visual dashboards. Dashboards are interactive performance management tools
that use graphic and easy-to-use formats to present specific metrics or key performance
indicators (KPIs) on a single computer screen (Ghazisaeidi, 2015). Implementing a dashboard
can help TGH improve quality of care and patient safety.
ADVERSE EVENT OR NEAR MISS ANALYSIS 6
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Studies show that the use of data-driven dashboards improves patient safety and
accelerates cost reduction efforts. A dashboard reduces human errors in processes and minimizes
the cognitive effort needed to make decisions, thereby saving time and increasing efficiency and
accuracy. The KPIs aggregate data collected from various sources. For example, clinical data
incorporated into a dashboard include patient information gathered from physician or nurse
charts. A dashboard can also consolidate metrics about market dynamics, innovation for longterm sustainability, and availability of financial and human resources for managers to analyze
(Weiner, Balijepally, & Tanniru, 2015).
To help TGH efficiently customize the dashboard to its specific clinical context, the tool
should be tested and evaluated using certain criteria. The categories for each criterion are as
follows: (a) easy customization, (b) knowledge discovery, (c) security, (d) information delivery,
(e) visual design, (f) alerts, and (g) system connectivity and integration (Karami, 2014). These
criteria can be used for all types of dashboards and health care settings.
While the design features are important, the dashboard is only useful if the KPIs provide
valuable data. Hence, the selection and development of KPIs are critical steps in QI at TGH
without which the organization runs the risk of ignoring areas that require corrective action
(Ghazisaeidi, 2015).
Relevant Metrics of Quality Improvement for TrueWill General Hospital
The KPIs are the most valuable content in a dashboard. They measure performance
across the organization using a combination of administrative and clinical data sets. To prevent
overloading the electronic dashboard, only a limited number of KPIs concerning high-priority
areas are selected. These KPIs are based on evidence-based academic literature. Data for each
KPI is sourced from different source systems in the organization such as accounting system,
ADVERSE EVENT OR NEAR MISS ANALYSIS 7
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human resources system, and clinical system (Ghazisaeidi, 2015). For example, clinical data are
sourced from reports on whether clinicians treated the correct patient, addressed the equipment
or supplies needs, prescribed the correct medication or anesthesia at the appropriate time, and
detected patient allergies (Hagland, 2012). For the adverse event analysis report, the relevant
KPIs will focus on clinical and patient-centric metrics.
Health care agencies such as the Agency for Healthcare Research and Quality (AHRQ)
have developed their own sets of metrics that address various aspects of quality—patient safety,
prevention quality, inpatient quality, and pediatric quality. TGH can customize its clinical and
patient-centric KPIs for the dashboard from these aspects. Examples of relevant AHRQ metrics
that are applicable to the ED adverse event include (a) death rate in low-mortality diagnosis
related groups, (b) accidental puncture or laceration rate, (c) heart failure mortality rate, and (d)
dehydration admission rate (AHRQ, 2015a, 2015b, 2015c).
The ED department at THG can include other relevant KPIs in the dashboard such as (a)
monthly averages for patient length of stay (inpatient and outpatient); (b) patients in the ED who
left without being seen (monthly); (c) radiology test (CT scan and x-ray), start to final dictation
turnaround time (Weiner, Balijepally, & Tanniru, 2015); (d) speed of onset of pain relief; (e) cost
reduction percentage per patient; and (f) risk of drug interactions (Dolan, Veazie, & Russ, 2013).
The evidence-base for the selected KPIs consists of peer-reviewed studies. Hagland
(2012) proved the success of the dashboard for patient safety optimization at the Saint Luke’s
Mid America Heart Institute, Missouri. The dashboard increased communication within medical
teams, reduced safety errors, and improved coordination between the teams. Dolan, Veazie, and
Russ (2013) studied the effectiveness of the electronic dashboard as a decision-making tool. The
results showed that the dashboard had potential to foster informed decision-making and patient-
ADVERSE EVENT OR NEAR MISS ANALYSIS 8
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centered care. Weiner, Balijepally, and Tanniru (2015) studied the integration of data-driven
dashboards at the St. Joseph Mercy Oakland Hospital in Michigan. The study reported tangible
benefits such as KPIs reporting reduced adverse event rates and intangible benefits such as
increased accountability across the organization, self-improvement among nurses, and improved
unit performance.
The dashboard is just the technological component of quality improvement. TGH
requires a broader QI framework that incorporates organizational strategies to overcome
problems in the ED that resulted in the death of the patient. A suitable framework will be selected
after evaluating different perspectives and data about quality improvement.
Outline for a Quality Improvement Initiative for TrueWill General Hospital
The health care industry has adopted and adapted many QI and measurement models over
the years. Two popular models in quality improvement are the six sigma and lean models. Both
models have similar goals—eliminate operational waste and defects to improve quality and
efficiency of a system. The main difference between the six sigma and lean is in the approaches
to identifying the cause of defects and errors. According to six sigma, variations in processes
cause errors, while lean thinking highlights unnecessary steps as the cause of operational waste
and errors (AHRQ, 2017).
As both process variations and unnecessary steps can cause errors, the combination of the
lean and six sigma models can be implemented at TGH as its quality improvement outline. The
hospital can follow the lean six sigma model’s DMAIC approach. DMAIC is a five-step
approach to process improvement: (a) define—identify key business issues; (b) measure—
understand current levels of performance; (c) analyze—identify root causes of process errors; (d)
improve—introduce strategies and tools to improve quality of process; and (e) control—maintain
ADVERSE EVENT OR NEAR MISS ANALYSIS 9
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new levels of performance across the organization (Huber, 2017). Implementing the lean six
sigma into all units and departments, not just the ED, at TGH will help streamline processes in a
proactive manner. By improving the whole system, the hospital can prevent communication gaps
or errors, disorganization, and breakdown of faulty systems. DMAIC steps will allow TGH to
enhance QI process using tools and strategies such as the dashboard.
The Institute of Health Improvement’s plan-do-study-act (PDSA) model and the Baldrige
criteria were other quality improvement perspectives that were considered (Huber, 2017).
However, the PDSA insufficiently addressed specific types of errors caused by variations or
unnecessary steps, unlike the lean six sigma model. The Baldrige criteria too were insufficient
because their usage was more suitable for enabling educational excellence. Additionally, there is
extensive evidence supporting the lean and six sigma models in quality improvement.
While the lean six sigma model and dashboards have a high success-rate, implementing
the QI initiative depends on coordinated and collaborative efforts by multiple stakeholders.
Teamwork enables TGH’s health care professionals to optimize systems factors and the quality
of processes and prevent future adverse events.
MSN 6016 Assessment 1 Adverse Event or Near Miss Analysis Conclusion
The process of QI and ensuring patient safety is challenging because health care
organizations must simultaneously provide the highest quality of services and introduce cost
reduction strategies. Quality improvement initiatives, such as implementing dashboards, must
focus on finding and fixing the root causes of errors or process inefficiencies. To identify the root
causes of errors, the organization should train health care professionals, update health care
technologies, and open lines of communication to meet the expectations of patients for safe,
timely, affordable, and quality care.
ADVERSE EVENT OR NEAR MISS ANALYSIS 10
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MSN 6016 Assessment 1 Adverse Event or Near Miss Analysis References
Agency for Healthcare Research and Quality. (2015a). Prevention quality indicators. Retrieved
from https://qualityindicators.ahrq.gov/Downloads/Modules/PQI/V50/PQI_Brochure.pdf
Agency for Healthcare Research and Quality. (2015b). Patient safety indicators. Retrieved from
https://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50/PSI_Brochure.pdf
Agency for Healthcare Research and Quality. (2015c). Inpatient quality indicators. Retrieved
from https://qualityindicators.ahrq.gov/Downloads/Modules/IQI/V50/IQI_Brochure.pdf
Agency for Healthcare Research and Quality. (2017). Section 4: Ways to approach the quality
improvement process. In The CAHPS ambulatory care improvement guide: Practical
strategies for improving patient experience. Retrieved from
https://ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qiprocess/sect4part2.html#4c
Allen, M. (2013, September 19). How many die from medical mistakes in U.S. hospitals?
[Ongoing investigative report]. ProPublica. Retrieved from
https://propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals
Bernhard, B. (2013, May 5). Medical errors leave devastating impact on families, professionals.
St. Louis Post-Dispatch. Retrieved from http://stltoday.com/lifestyles/health-medfit/health/medical-errors-leave-devastating-impact-on-familiesprofessionals/article_0cb6f031-fbc6-5b8f-bed9-610163dbf2f8.html
Dolan, J. G., Veazie, P. J., & Russ, A. J. (2013). Development and initial evaluation of a
treatment decision dashboard. BMC Medical Informatics and Decision Making, 13(1), 51.
Retrieved from https://search-proquest-com.library.capella.edu/docview/1347649264?pqorigsite=summon
ADVERSE EVENT OR NEAR MISS ANALYSIS 11
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Hagland, M. (2012). A dashboard for OR patient safety optimization. Healthcare
Informatics, 29(8), 29–31. Retrieved from https://search-proquestcom.library.capella.edu/docview/1038458450?pqorigsite=summon&http://library.capella.edu/login%3furl=accountid=27965
Huber, D. L. (2017). Leadership and nursing care management (6th ed.) Philadelphia: W.B.
Saunders. http://dx.doi.org/10.7748/nm.21.6.13.s14
Ghazisaeidi, M., Safdari, R., Torabi, M., Mirzaee, M., Farzi, J., & Goodini, A. (2015).
Development of performance dashboards in healthcare sector: Key practical issues. Acta
Informatica Medica, 23(5), 317–321. Retrieved from https://search-proquestcom.library.capella.edu/docview/1727377974?pq-origsite=summon
Karami, M. (2014). A design protocol to develop radiology dashboards. Acta Informatica
Medica, 22(5), 341–346. http://dx.doi.org/10.5455/aim.2014.22.341-346
Manias, E. (2012). Looking for meds in all the wrong places [Case study commentary].
Retrieved from https://psnet.ahrq.gov/webmm/case/282/looking-for-meds-in-all-thewrong-places?q=Looking+for+meds+in+all+the+wrong+place
Mira, J. J., Lorenzo, S., Carrillo, I., Ferrús, L., Pérez-Pérez, P., Iglesias, F.,… Astier, P. (2015).
Interventions in health organisations to reduce the impact of adverse events in second and
third victims. BMC Health Services Research, 15(1), 341–350. Retrieved from
https://search-proquest-com.library.capella.edu/docview/1780186926?pqorigsite=summon&http://library.capella.edu/login%3furl=accountid=27965
Weiner, J., Balijepally, V., & Tanniru, M. (2015). Integrating strategic and operational decision
making using data-driven dashboards: The case of St. Joseph Mercy Oakland
Hospital. Journal of Healthcare Management, 60(5), 319–331. Retrieved from
Comment [JS2]: I would suggest
locating a more current reference.
This reference is on the cusp of being
outdated according to health care
research standards of being less than
five years. With this topic, I am sure
there are more updated references that
could be used instead.
Comment [JS3]: This is another
reference that should be updated for
the above reasons.
ADVERSE EVENT OR NEAR MISS ANALYSIS 12
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https://search-proquestcom.library.capella.edu/docview/1733617419?OpenUrlRefId=info:xri/sid:summon&acco
untid=27965
A Sample Answer For the Assignment: MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis
Title: MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis
MSN 6016 Assessment 1 Adverse Event or Near Miss Analysis Grading Rubric
| Performance Category | 100% or highest level of performance
100% 16 points |
Very good or high level of performance
88% 14 points |
Acceptable level of performance
81% 13 points |
Inadequate demonstration of expectations
68% 11 points |
Deficient level of performance
56% 9 points
|
Failing level
of performance 55% or less 0 points |
| Total Points Possible= 50 | 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points |
| Scholarliness
Demonstrates achievement of scholarly inquiry for professional and academic topics. |
Presentation of information was exceptional and included all of the following elements:
|
Presentation of information was good, but was superficial in places and included all of the following elements:
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Presentation of information was minimally demonstrated in all of the following elements:
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Presentation of information is unsatisfactory in one of the following elements:
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Presentation of information is unsatisfactory in two of the following elements:
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Presentation of information is unsatisfactory in three or more of the following elements
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| 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points | |
| Application of Course Knowledge
Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations |
Presentation of information was exceptional and included all of the following elements:
|
Presentation of information was good, but was superficial in places and included all of the following elements:
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Presentation of information was minimally demonstrated in the all of the following elements:
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Presentation of information is unsatisfactory in one of the following elements:
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Presentation of information is unsatisfactory in two of the following elements:
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Presentation of information is unsatisfactory in three of the following elements
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| 10 Points | 9 Points | 6 Points | 0 Points | |||
| Interactive Dialogue
Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic. |
Demonstrated all of the following:
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Demonstrated 3 of the following:
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Demonstrated 2 of the following:
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Demonstrated 1 or less of the following:
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||
| 8 Points | 7 Points | 6 Points | 5 Points | 4 Points | 0 Points | |
| Grammar, Syntax, APA
Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error. |
The following was present:
AND
AND
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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| 0 Points Deducted | 5 Points Lost | |||||
| Participation
Requirements |
Demonstrated the following:
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Failed to demonstrate the following:
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| 0 Points Lost | 5 Points Lost | |||||
| Due Date Requirements | Demonstrated all of the following:
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |
Demonstrates one or less of the following.
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |