Sample Answer for MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis Included After Question<\/strong><\/h2>\nMSN 6016 Assessment 1\u00a0 Adverse Event or Near Miss Analysis<\/p>\n
Preparation<\/strong><\/h2>\nPrepare 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.<\/p>\n
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.<\/p>\n
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.<\/p>\n
Analyze the missed steps or protocol deviations related to an adverse event or near miss.<\/p>\n
Describe how the event resulted from a patient\u2019s medical management<\/a> rather than from the underlying condition.<\/p>\nIdentify and evaluate the missed steps or protocol deviations that led to the event.<\/p>\n
Discuss the extent to which the incident was preventable.<\/p>\n
Research the impact of the same type of adverse event or near miss in other facilities.<\/p>\n
Analyze the implications of the adverse event or near miss for all stakeholders.<\/p>\n
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.<\/p>\n![\"MSN](\"http:\/\/nursingassignmentcrackers.com\/wp-content\/uploads\/2021\/08\/MSN-6016-Assessment-1-Adverse-Event-or-Near-Miss-Analysis-1-300x138.png\")
MSN 6016 Assessment 1\u00a0 Adverse Event or Near Miss Analysis<\/figcaption><\/figure>\nClick here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis<\/strong><\/a><\/span><\/p>\nAnalyze the responsibilities and actions of the inter-professional team. Explain what measures should have been taken and identify<\/p>\n
the responsible parties or roles.<\/p>\n
Describe any change to process or protocol implemented after the incident.<\/p>\n
Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.<\/p>\n
Analyze the quality improvement technologies that were put in place to increase patient safety and prevent a repeat of similar events.<\/p>\n
Determine whether the technologies are being utilized appropriately.<\/p>\n
Explore how other institutions integrated solutions to prevent these types of events.<\/p>\n
Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.<\/p>\n
Identify the salient data that is associated with the adverse event or near miss that is generated from the facility\u2019s 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<\/a>.)<\/p>\nAnalyze what the relevant metrics show.<\/p>\n
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.<\/p>\n
Outline a quality improvement initiative to prevent a future adverse event or near miss.<\/p>\n
Explain how the process or protocol is now managed and monitored in your facility.<\/p>\n
Evaluate how other institutions addressed similar incidents or events.<\/p>\n
Analyze QI initiatives developed to prevent similar incidents, and explain why they are successful. Provide evidence of their success.<\/p>\n
Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.<\/p>\n
Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.<\/p>\n
Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.<\/p>\n
Running head: ADVERSE EVENT OR NEAR MISS ANALYSIS 1<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\nAdverse Event or Near Miss Analysis
\nLearner\u2019s Name
\nCapella University
\nQuality Improvement for Interprofessional Care
\nAdverse Event or Near Miss Analysis
\nJuly, 2017
\nComment [JS1]: This submission is
\nvery well crafted according to the
\nrubric. The submission is written in a
\nscholarly voice and free of APA and
\ngrammatical errors.<\/p>\n
ADVERSE EVENT OR NEAR MISS ANALYSIS 2<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\nAdverse Event or Near Miss Analysis
\nPreventable adverse events are among the top causes of death in the United States.
\nEstimates reveal that 210,000 to 400,000 fatal adverse events occur every year (Allen, 2013).
\nExamples of preventable adverse events are hospital-acquired diseases, medication errors, and
\npatient falls. The focus of this adverse event analysis is medication errors, also known as adverse
\ndrug events (ADEs), such as medication overdoses or administration of wrong medicines. The
\nanalysis will recommend strategies to mitigate ADEs based on a case of medication overdose
\nobserved in the emergency department (ED) at TrueWill General Hospital (TGH), a
\nmultispecialty hospital in the United States.
\nA 40-year-old woman was brought to the ED after suffering a seizure. Before she was
\ndischarged, she suffered another seizure and the ED doctor prescribed 800 mg of phenytoin, an
\nanti-seizure medication, to be given intravenously (IV). The ED nurse misread the prescribed
\ndosage in the electronic medical record (EMR) and administered 8000 mg, which was 10-fold
\ngreater than the prescribed dosage. The patient died soon after the lethal infusion (Manias, 2012).
\nThe incident shows that the nurse made a series of cognitive errors in medication
\nmanagement and missed key steps (Manias, 2012), which will be explained in the analysis
\nreport. Additionally, the analysis will examine the implications of adverse events on multiple
\nstakeholders. Relevant evidence and metrics will be incorporated when making suggestions for
\nimprovement of patient safety at TrueWill General Hospital.
\nAnalysis of Missed Steps Related to the Adverse Event
\nEmergency departments are susceptible to adverse events because of the unscheduled
\nnature of patient presentation, urgency, and severity of cases. In such high-pressure situations,<\/p>\n
ADVERSE EVENT OR NEAR MISS ANALYSIS 3<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\nclinicians must be more careful when treating a patient (Manias, 2012). Retracing the steps taken
\nby the nurse revealed several missed steps in the delivery of care.
\nTo begin with, the drug dispensing machines in the ED were stocked with phenytoin in
\n250 mg vials; the correct dose required only 3.2 vials. As the nurse had misread the dose, she
\nneeded 32 vials of the drug. She took the vials from three different drug dispensers and
\nadministered the dose using two IV bags as well as a piggyback line (Manias, 2012). The nurse
\ndid not question the difficulty in procuring and administering the drugs; nor did she ask anyone
\nto validate her calculations. Furthermore, she was not asked why she was removing so many
\nvials from the drug dispensers in the ED unit.
\nThe scenario also shows that the nurse was unaware of the toxic nature of phenytoin
\nwhen administered in large quantities; she was unable to recognize the warning signs.
\nAdditionally, the fact that the nurse could remove 32 vials is evidence of the technical drawbacks
\nof the automated drug dispensing machines. The machines were not programed to send out alerts
\nwhen large quantities of medications, especially high-alert medication like phenytoin, were
\ndispensed (Manias, 2012). They were also not synced to the patient\u2019s medical record. Therefore,
\nthe machines contained no information on drug preparation or correct dosages and did not
\ndisplay any warning signs.
\nVarious systems factors such as communication, leadership, education, training, and
\ninnovation of health care technology influenced the ED nurse\u2019s clinical performance. The factors
\noriginate from the adaptation of systems theory into health care (Huber, 2017). There are,
\nhowever, areas of uncertainty regarding the factors becoming problematic in TGH\u2019s scenario. For
\nexample, the nurse\u2019s hesitation to consult her team could have been caused by staff management
\nproblems such as conflict, overwork, or shortage of ED staff. Similarly, her lack of awareness of<\/p>\n
ADVERSE EVENT OR NEAR MISS ANALYSIS 4<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\ndosages and safety measures shows gaps in education and training. Such problems are a result of
\na breakdown of systems factors. Further evaluation is essential to understand the root causes of
\nadverse events and systems problems. Ignoring root causes can result in similar adverse events in
\nthe future and negatively impact the stakeholders.
\nImplications of the Adverse Event on Stakeholders
\nSince medicine is a profession that depends on interpersonal relationships, adverse events
\nhave unintended emotional, psychological, and professional consequences on all stakeholders.
\nPatients and their families are the first victims of adverse events, while health care professionals
\nand the organization become the second and third victims, respectively (Mira et al., 2015). A
\nsimilar inference can be made about the adverse event at TGH; the inference is supported by
\ncertain assumptions about the health care environment. General assumptions about health care
\nare as follows: (a) quality health care is a result of positive relationships between all stakeholders
\n(Huber, 2017), (b) stakeholders are part of a high-risk environment where errors in clinical
\npractice are common, (c) health care professionals are not always responsible for errors as errors
\nare often caused by a breakdown in systems factors (Manias, 2012), and (d) errors diminish the
\nmorale and job satisfaction of health care professionals and lead to more adverse events (Huber,
\n2017).
\nThe analysis of implications on stakeholders begins with identifying how each category
\nof victims is impacted. The first victims expect hospital stays and procedures to be safe and
\nbeneficial. When a patient suffers an injury, or dies because of medical negligence, the family
\nmay feel aggrieved and may require counseling and support. They may feel unnerved and scared
\nby health care professionals (Bernhard, 2013) and hesitate to seek medical treatment in the
\nfuture. The study reported that health care professionals were traumatized after committing a<\/p>\n
ADVERSE EVENT OR NEAR MISS ANALYSIS 5<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\npreventable error or witnessing an adverse event. They may lose confidence, abandon their
\ncareers (Bernhard, 2013), and experience anxiety or depression (Mira et al., 2015). Adverse
\nevents are damaging to careers, and nursing professionals may face difficulty in finding another
\njob (Bernhard, 2013).
\nAdverse events also affect the organization\u2014the third victim\u2014by damaging its
\nreputation. Adverse events can discourage people from seeking treatment at a particular hospital
\n(Mira et. al, 2015). Moreover, as most preventable errors are not covered by Medicaid and
\nMedicare services, the hospital can stand to lose a significant amount of reimbursement money.
\nIt is important that health care organizations such as TGH find ways to minimize the
\nimpact of adverse events on different stakeholders. The current trend in quality improvement
\n(QI) is focused on reducing human errors through automation of health care technologies. In the
\ncase of TGH, the existing level of automation of patient records and drug dispensers is not
\nsufficient and needs to be replaced. The next section recommends and discusses the benefits of a
\npopular QI technology\u2014patient care dashboards.
\nEvaluation of Quality Improvement Technologies
\nPerformance measurement and reporting by health care professionals are the crux of QI
\nbecause transmitting, organizing, analyzing, and displaying performance data help in identifying
\nareas that need improvement (Ghazisaeidi, 2015). A recent development in QI technologies is the
\nintroduction of visual dashboards. Dashboards are interactive performance management tools
\nthat use graphic and easy-to-use formats to present specific metrics or key performance
\nindicators (KPIs) on a single computer screen (Ghazisaeidi, 2015). Implementing a dashboard
\ncan help TGH improve quality of care and patient safety.<\/p>\n
ADVERSE EVENT OR NEAR MISS ANALYSIS 6<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\nStudies show that the use of data-driven dashboards improves patient safety and
\naccelerates cost reduction efforts. A dashboard reduces human errors in processes and minimizes
\nthe cognitive effort needed to make decisions, thereby saving time and increasing efficiency and
\naccuracy. The KPIs aggregate data collected from various sources. For example, clinical data
\nincorporated into a dashboard include patient information gathered from physician or nurse
\ncharts. A dashboard can also consolidate metrics about market dynamics, innovation for long\u0002term sustainability, and availability of financial and human resources for managers to analyze
\n(Weiner, Balijepally, & Tanniru, 2015).
\nTo help TGH efficiently customize the dashboard to its specific clinical context, the tool
\nshould be tested and evaluated using certain criteria. The categories for each criterion are as
\nfollows: (a) easy customization, (b) knowledge discovery, (c) security, (d) information delivery,
\n(e) visual design, (f) alerts, and (g) system connectivity and integration (Karami, 2014). These
\ncriteria can be used for all types of dashboards and health care settings.
\nWhile the design features are important, the dashboard is only useful if the KPIs provide
\nvaluable data. Hence, the selection and development of KPIs are critical steps in QI at TGH
\nwithout which the organization runs the risk of ignoring areas that require corrective action
\n(Ghazisaeidi, 2015).
\nRelevant Metrics of Quality Improvement for TrueWill General Hospital
\nThe KPIs are the most valuable content in a dashboard. They measure performance
\nacross the organization using a combination of administrative and clinical data sets. To prevent
\noverloading the electronic dashboard, only a limited number of KPIs concerning high-priority
\nareas are selected. These KPIs are based on evidence-based academic literature. Data for each
\nKPI is sourced from different source systems in the organization such as accounting system,<\/p>\n
ADVERSE EVENT OR NEAR MISS ANALYSIS 7<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\nhuman resources system, and clinical system (Ghazisaeidi, 2015). For example, clinical data are
\nsourced from reports on whether clinicians treated the correct patient, addressed the equipment
\nor supplies needs, prescribed the correct medication or anesthesia at the appropriate time, and
\ndetected patient allergies (Hagland, 2012). For the adverse event analysis report, the relevant
\nKPIs will focus on clinical and patient-centric metrics.
\nHealth care agencies such as the Agency for Healthcare Research and Quality (AHRQ)
\nhave developed their own sets of metrics that address various aspects of quality\u2014patient safety,
\nprevention quality, inpatient quality, and pediatric quality. TGH can customize its clinical and
\npatient-centric KPIs for the dashboard from these aspects. Examples of relevant AHRQ metrics
\nthat are applicable to the ED adverse event include (a) death rate in low-mortality diagnosis
\nrelated groups, (b) accidental puncture or laceration rate, (c) heart failure mortality rate, and (d)
\ndehydration admission rate (AHRQ, 2015a, 2015b, 2015c).
\nThe ED department at THG can include other relevant KPIs in the dashboard such as (a)
\nmonthly averages for patient length of stay (inpatient and outpatient); (b) patients in the ED who
\nleft without being seen (monthly); (c) radiology test (CT scan and x-ray), start to final dictation
\nturnaround time (Weiner, Balijepally, & Tanniru, 2015); (d) speed of onset of pain relief; (e) cost
\nreduction percentage per patient; and (f) risk of drug interactions (Dolan, Veazie, & Russ, 2013).
\nThe evidence-base for the selected KPIs consists of peer-reviewed studies. Hagland
\n(2012) proved the success of the dashboard for patient safety optimization at the Saint Luke\u2019s
\nMid America Heart Institute, Missouri. The dashboard increased communication within medical
\nteams, reduced safety errors, and improved coordination between the teams. Dolan, Veazie, and
\nRuss (2013) studied the effectiveness of the electronic dashboard as a decision-making tool. The
\nresults showed that the dashboard had potential to foster informed decision-making and patient-<\/p>\n
ADVERSE EVENT OR NEAR MISS ANALYSIS 8<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\ncentered care. Weiner, Balijepally, and Tanniru (2015) studied the integration of data-driven
\ndashboards at the St. Joseph Mercy Oakland Hospital in Michigan. The study reported tangible
\nbenefits such as KPIs reporting reduced adverse event rates and intangible benefits such as
\nincreased accountability across the organization, self-improvement among nurses, and improved
\nunit performance.
\nThe dashboard is just the technological component of quality improvement. TGH
\nrequires a broader QI framework that incorporates organizational strategies to overcome
\nproblems in the ED that resulted in the death of the patient. A suitable framework will be selected
\nafter evaluating different perspectives and data about quality improvement.
\nOutline for a Quality Improvement Initiative for TrueWill General Hospital
\nThe health care industry has adopted and adapted many QI and measurement models over
\nthe years. Two popular models in quality improvement are the six sigma and lean models. Both
\nmodels have similar goals\u2014eliminate operational waste and defects to improve quality and
\nefficiency of a system. The main difference between the six sigma and lean is in the approaches
\nto identifying the cause of defects and errors. According to six sigma, variations in processes
\ncause errors, while lean thinking highlights unnecessary steps as the cause of operational waste
\nand errors (AHRQ, 2017).
\nAs both process variations and unnecessary steps can cause errors, the combination of the
\nlean and six sigma models can be implemented at TGH as its quality improvement outline. The
\nhospital can follow the lean six sigma model\u2019s DMAIC approach. DMAIC is a five-step
\napproach to process improvement: (a) define\u2014identify key business issues; (b) measure\u2014
\nunderstand current levels of performance; (c) analyze\u2014identify root causes of process errors; (d)
\nimprove\u2014introduce strategies and tools to improve quality of process; and (e) control\u2014maintain<\/p>\n
ADVERSE EVENT OR NEAR MISS ANALYSIS 9<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\nnew levels of performance across the organization (Huber, 2017). Implementing the lean six
\nsigma into all units and departments, not just the ED, at TGH will help streamline processes in a
\nproactive manner. By improving the whole system, the hospital can prevent communication gaps
\nor errors, disorganization, and breakdown of faulty systems. DMAIC steps will allow TGH to
\nenhance QI process using tools and strategies such as the dashboard.
\nThe Institute of Health Improvement\u2019s plan-do-study-act (PDSA) model and the Baldrige
\ncriteria were other quality improvement perspectives that were considered (Huber, 2017).
\nHowever, the PDSA insufficiently addressed specific types of errors caused by variations or
\nunnecessary steps, unlike the lean six sigma model. The Baldrige criteria too were insufficient
\nbecause their usage was more suitable for enabling educational excellence. Additionally, there is
\nextensive evidence supporting the lean and six sigma models in quality improvement.
\nWhile the lean six sigma model and dashboards have a high success-rate, implementing
\nthe QI initiative depends on coordinated and collaborative efforts by multiple stakeholders.
\nTeamwork enables TGH\u2019s health care professionals to optimize systems factors and the quality
\nof processes and prevent future adverse events.<\/p>\n
MSN 6016 Assessment 1\u00a0 Adverse Event or Near Miss Analysis <\/em><\/strong>Conclusion<\/h3>\nThe process of QI and ensuring patient safety is challenging because health care
\norganizations must simultaneously provide the highest quality of services and introduce cost
\nreduction strategies. Quality improvement initiatives, such as implementing dashboards, must
\nfocus on finding and fixing the root causes of errors or process inefficiencies. To identify the root
\ncauses of errors, the organization should train health care professionals, update health care
\ntechnologies, and open lines of communication to meet the expectations of patients for safe,
\ntimely, affordable, and quality care.<\/p>\n
ADVERSE EVENT OR NEAR MISS ANALYSIS 10<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.<\/p>\n
MSN 6016 Assessment 1\u00a0 Adverse Event or Near Miss Analysis <\/em><\/strong>References<\/h3>\nAgency for Healthcare Research and Quality. (2015a). Prevention quality indicators. Retrieved
\nfrom https:\/\/qualityindicators.ahrq.gov\/Downloads\/Modules\/PQI\/V50\/PQI_Brochure.pdf<\/a>
\nAgency for Healthcare Research and Quality. (2015b). Patient safety indicators. Retrieved from
\nhttps:\/\/qualityindicators.ahrq.gov\/Downloads\/Modules\/PSI\/V50\/PSI_Brochure.pdf<\/a>
\nAgency for Healthcare Research and Quality. (2015c). Inpatient quality indicators. Retrieved
\nfrom https:\/\/qualityindicators.ahrq.gov\/Downloads\/Modules\/IQI\/V50\/IQI_Brochure.pdf<\/a>
\nAgency for Healthcare Research and Quality. (2017). Section 4: Ways to approach the quality
\nimprovement process. In The CAHPS ambulatory care improvement guide: Practical
\nstrategies for improving patient experience. Retrieved from
\nhttps:\/\/ahrq.gov\/cahps\/quality-improvement\/improvement-guide\/4-approach-qi\u0002process\/sect4part2.html#4c<\/a>
\nAllen, M. (2013, September 19). How many die from medical mistakes in U.S. hospitals?
\n[Ongoing investigative report]. ProPublica. Retrieved from
\nhttps:\/\/propublica.org\/article\/how-many-die-from-medical-mistakes-in-us-hospitals<\/a>
\nBernhard, B. (2013, May 5). Medical errors leave devastating impact on families, professionals.
\nSt. Louis Post-Dispatch. Retrieved from http:\/\/stltoday.com\/lifestyles\/health-med\u0002fit\/health\/medical-errors-leave-devastating-impact-on-families\u0002professionals\/article_0cb6f031-fbc6-5b8f-bed9-610163dbf2f8.html<\/a>
\nDolan, J. G., Veazie, P. J., & Russ, A. J. (2013). Development and initial evaluation of a
\ntreatment decision dashboard. BMC Medical Informatics and Decision Making, 13(1), 51.
\nRetrieved from https:\/\/search-proquest-com.library.capella.edu\/docview\/1347649264?pq\u0002origsite=summon<\/a><\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 11<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\nHagland, M. (2012). A dashboard for OR patient safety optimization. Healthcare
\nInformatics, 29(8), 29\u201331. Retrieved from https:\/\/search-proquest\u0002com.library.capella.edu\/docview\/1038458450?pq\u0002origsite=summon&http:\/\/library.capella.edu\/login%3furl=accountid=27965
\nHuber, D. L. (2017). Leadership and nursing care management (6th ed.) Philadelphia: W.B.
\nSaunders. http:\/\/dx.doi.org\/10.7748\/nm.21.6.13.s14<\/a>
\nGhazisaeidi, M., Safdari, R., Torabi, M., Mirzaee, M., Farzi, J., & Goodini, A. (2015).
\nDevelopment of performance dashboards in healthcare sector: Key practical issues. Acta
\nInformatica Medica, 23(5), 317\u2013321. Retrieved from https:\/\/search-proquest\u0002com.library.capella.edu\/docview\/1727377974?pq-origsite=summon
\nKarami, M. (2014). A design protocol to develop radiology dashboards. Acta Informatica
\nMedica, 22(5), 341\u2013346. http:\/\/dx.doi.org\/10.5455\/aim.2014.22.341-346<\/a>
\nManias, E. (2012). Looking for meds in all the wrong places [Case study commentary].
\nRetrieved from https:\/\/psnet.ahrq.gov\/webmm\/case\/282\/looking-for-meds-in-all-the\u0002wrong-places?q=Looking+for+meds+in+all+the+wrong+place<\/a>
\nMira, J. J., Lorenzo, S., Carrillo, I., Ferr\u00fas, L., P\u00e9rez-P\u00e9rez, P., Iglesias, F.,\u2026 Astier, P. (2015).
\nInterventions in health organisations to reduce the impact of adverse events in second and
\nthird victims. BMC Health Services Research, 15(1), 341\u2013350. Retrieved from
\nhttps:\/\/search-proquest-com.library.capella.edu\/docview\/1780186926?<\/a>pq\u0002origsite=summon&http:\/\/library.capella.edu\/login%3furl=accountid=27965<\/a>
\nWeiner, J., Balijepally, V., & Tanniru, M. (2015). Integrating strategic and operational decision
\nmaking using data-driven dashboards: The case of St. Joseph Mercy Oakland
\nHospital. Journal of Healthcare Management, 60(5), 319\u2013331. Retrieved from
\nComment [JS2]: I would suggest
\nlocating a more current reference.
\nThis reference is on the cusp of being
\noutdated according to health care
\nresearch standards of being less than
\nfive years. With this topic, I am sure
\nthere are more updated references that
\ncould be used instead.
\nComment [JS3]: This is another
\nreference that should be updated for
\nthe above reasons.<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 12<\/h3>\n
Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.
\nhttps:\/\/search-proquest\u0002com.library.capella.edu\/docview\/1733617419?OpenUrlRefId=info:xri\/sid:summon&acco
\nuntid=27965<\/p>\n
A Sample Answer For the Assignment: MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis<\/strong><\/h2>\nTitle: MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis<\/strong><\/h2>\nMSN 6016 Assessment 1\u00a0 Adverse Event or Near Miss Analysis <\/em>Grading Rubric<\/strong><\/h3>\n\n\n\nPerformance Category<\/strong><\/td>\n100% or highest level of performance<\/strong><\/p>\n100%<\/strong><\/p>\n16 points<\/strong><\/td>\nVery good or high level of performance<\/strong><\/p>\n88%<\/strong><\/p>\n14 points<\/strong><\/td>\nAcceptable level of performance<\/strong><\/p>\n81%<\/strong><\/p>\n13 points<\/strong><\/td>\nInadequate demonstration of expectations<\/strong><\/p>\n68%<\/strong><\/p>\n11 points<\/strong><\/td>\nDeficient level of performance<\/strong><\/p>\n56%<\/strong><\/p>\n9 points<\/strong><\/p>\n\u00a0<\/strong><\/td>\nFailing level<\/strong><\/p>\nof performance<\/strong><\/p>\n55% or less<\/strong><\/p>\n0 points<\/strong><\/td>\n<\/tr>\n<\/thead>\n\n\n\u00a0Total Points Possible= 50 <\/strong><\/td>\n\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 16 Points<\/strong><\/td>\n\u00a0\u00a0 14 Points<\/strong><\/td>\n13 Points<\/strong><\/td>\n\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 11 Points<\/strong><\/td>\n\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 9 Points<\/strong><\/td>\n\u00a0 \u00a0 \u00a0 \u00a0\u00a0 0 Points<\/strong><\/td>\n<\/tr>\n\nScholarliness<\/strong><\/p>\nDemonstrates achievement of scholarly inquiry for professional and academic topics.<\/td>\n
Presentation of information was exceptional and included all<\/strong> of the following elements:<\/p>\n\n- Provides evidence of scholarly inquiry relevant to required TD topic(s).<\/li>\n
- Presents specific information from scholarly sources to develop a comprehensive presentation of facts.<\/li>\n
- Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*<\/li>\n
- Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.<\/li>\n<\/ul>\n<\/td>\n
Presentation of information was good, but was superficial in places and included all of the following elements:<\/p>\n\n- Provides evidence of scholarly inquiry relevant to required TD topic(s).<\/li>\n
- Presents specific information from scholarly sources to develop a comprehensive presentation of facts.<\/li>\n
- Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*<\/li>\n
- Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.<\/li>\n<\/ul>\n<\/td>\n
Presentation of information was minimally demonstrated in all of the following elements:<\/p>\n\n- Provides evidence of scholarly inquiry relevant to required TD topic(s).<\/li>\n
- Presents specific information from scholarly sources to develop a comprehensive presentation of facts.<\/li>\n
- Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*<\/li>\n
- Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.<\/li>\n<\/ul>\n<\/td>\n
<\/p>\nPresentation of information is unsatisfactory in one<\/strong> of the following elements:<\/p>\n\n- Provides evidence of scholarly inquiry relevant to required TD topic(s).<\/li>\n
- Presents specific information from scholarly sources to develop a comprehensive presentation of facts.<\/li>\n
- Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*<\/li>\n
- Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.<\/li>\n<\/ul>\n<\/td>\n
<\/p>\nPresentation of information is unsatisfactory in two<\/strong> of the following elements:<\/p>\n\n- Provides evidence of scholarly inquiry relevant to required TD topic(s).<\/li>\n
- Presents specific information from scholarly sources to develop a comprehensive presentation of facts.<\/li>\n
- Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*<\/li>\n
- Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.<\/li>\n<\/ul>\n<\/td>\n
Presentation of information is unsatisfactory in three<\/strong> or more<\/strong> of the following elements<\/p>\n\n- Provides evidence of scholarly inquiry relevant to required TD topic(s).<\/li>\n
- Presents specific information from scholarly sources to develop a comprehensive presentation of facts.<\/li>\n
- Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*<\/li>\n
- Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
\n<\/td>\n \u00a016 Points<\/strong><\/td>\n\u00a014 Points<\/strong><\/td>\n\u00a013 Points<\/strong><\/td>\n11 Points<\/strong><\/td>\n9 Points<\/strong><\/td>\n\u00a00 Points<\/strong><\/td>\n<\/tr>\n\nApplication of Course Knowledge<\/strong><\/p>\nDemonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations<\/strong><\/td>\nPresentation of information was exceptional and included all<\/strong> of the following elements:<\/p>\n\n- Applies principles, knowledge and information from scholarly resources to the required topic.<\/li>\n
- Applies facts, principles or concepts learned from scholarly resources to a professional experience.<\/li>\n
- Application of information is comprehensive and specific to the required topic.<\/li>\n<\/ul>\n<\/td>\n
Presentation of information was good, but was superficial in places and included all<\/strong> of the following elements:<\/p>\n\n- Applies principles, knowledge and information from scholarly resources to the required topic.<\/li>\n
- Applies facts, principles or concepts learned from scholarly resources to a professional experience.<\/li>\n
- Application of information is comprehensive and specific to the required topic.<\/li>\n<\/ul>\n<\/td>\n
Presentation of information was minimally demonstrated in the all<\/strong> of the following elements:<\/p>\n\n- Applies principles, knowledge and information from scholarly resources to the required topic.<\/li>\n
- Applies facts, principles or concepts learned from scholarly resources to a professional experience.<\/li>\n
- Application of information is comprehensive and specific to the required topic.<\/li>\n<\/ul>\n<\/td>\n
Presentation of information is unsatisfactory in one <\/strong>of the following elements:<\/p>\n\n- Applies principles, knowledge and information from scholarly resources to the required topic.<\/li>\n
- Applies facts, principles or concepts learned from and scholarly resources to a professional experience.<\/li>\n
- Application of information is comprehensive and specific to the required topic.<\/li>\n<\/ul>\n<\/td>\n
Presentation of information is unsatisfactory in two<\/strong> of the following elements:<\/p>\n\n- Applies principles, knowledge and information from scholarly resources to the required topic.<\/li>\n
- Applies facts, principles or concepts learned from scholarly resources to a professional experience.<\/li>\n
- Application of information is comprehensive and specific to the required topic.<\/li>\n<\/ul>\n<\/td>\n
Presentation of information is unsatisfactory in three<\/strong> of the following elements<\/p>\n\n- Applies principles, knowledge and information and scholarly resources to the required topic.<\/li>\n
- Applies facts, principles or concepts learned scholarly resources to a professional experience.<\/li>\n
- Application of information is comprehensive and specific to the required topic.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
\n\u00a0<\/strong><\/td>\n\u00a010 Points<\/strong><\/td>\n9 Points <\/strong><\/td>\n<\/td>\n <\/td>\n \u00a06 Points<\/strong><\/td>\n\u00a00 Points<\/strong><\/td>\n<\/tr>\n\nInteractive Dialogue <\/strong><\/p>\nInitial post should be a minimum of 300 words (references do not count toward word count)<\/strong><\/p>\nThe peer and instructor responses must be a minimum of 150 words each (references do not count toward word count)<\/strong><\/p>\nResponses are substantive and relate to the topic.<\/strong><\/td>\nDemonstrated all <\/strong>of the following:<\/p>\n\n- Initial post must be a minimum of 300 words.<\/li>\n
- The peer and instructor responses must be a minimum of 150 words each.<\/li>\n
- Responses are substantive<\/li>\n
- Responses are related to the topic of discussion.<\/li>\n<\/ul>\n<\/td>\n
Demonstrated 3 of the following:<\/p>\n\n- Initial post must be a minimum of 300 words.<\/li>\n
- The peer and instructor responses must be a minimum of 150 words each.<\/li>\n
- Responses are substantive<\/li>\n
- Responses are related to the topic of discussion.<\/li>\n<\/ul>\n<\/td>\n
<\/td>\n <\/td>\n Demonstrated 2 of the following:<\/p>\n\n- Initial post must be a minimum of 300 words.<\/li>\n
- The peer and instructor responses must be a minimum of 150 words each.<\/li>\n
- Responses are substantive<\/li>\n
- Responses are related to the topic of discussion.<\/li>\n<\/ul>\n<\/td>\n
Demonstrated 1 or less of the following:<\/p>\n\n- Initial post must be a minimum of 300 words.<\/li>\n
- The peer and instructor responses must be a minimum of 150 words each.<\/li>\n
- Responses are substantive<\/li>\n
- Responses are related to the topic of discussion.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
\n\u00a0<\/strong><\/td>\n8 Points<\/strong><\/td>\n7 Points<\/strong><\/td>\n\u00a06 Points<\/strong><\/td>\n\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 5 Points<\/strong><\/td>\n\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 4 Points<\/strong><\/td>\n\u00a00 Points<\/strong><\/td>\n<\/tr>\n\nGrammar, Syntax, APA <\/strong><\/p>\nPoints deducted for improper grammar, syntax and APA style of writing.<\/strong><\/p>\nThe source of information is the APA Manual 6th Edition<\/strong><\/p>\nError is defined to be a unique APA error. Same type of error is only counted as one error.<\/strong><\/td>\nThe following was present:<\/p>\n\n- 0-3 errors in APA format<\/li>\n<\/ul>\n
AND<\/p>\n
\n- Responses have 0-3 grammatical, spelling or punctuation errors<\/li>\n<\/ul>\n
AND<\/p>\n
\n- Writing style is generally clear, focused on topic,and facilitates communication.<\/li>\n<\/ul>\n<\/td>\n
The following was present:<\/p>\n\n- 4-6 errors in APA format.<\/li>\n<\/ul>\n
AND\/OR<\/p>\n
\n- Responses have 4-5 grammatical, spelling or punctuation errors<\/li>\n<\/ul>\n
AND\/OR<\/p>\n
\n- Writing style is somewhat focused on topic.<\/li>\n<\/ul>\n<\/td>\n
The following was present:<\/p>\n\n- 7-9 errors in APA format.<\/li>\n<\/ul>\n
AND\/OR<\/p>\n
\n- Responses have 6-7 grammatical, spelling or punctuation errors<\/li>\n<\/ul>\n
AND\/OR<\/p>\n
\n- Writing style is slightly focused on topic making discussion difficult to understand.<\/li>\n<\/ul>\n<\/td>\n
<\/p>\nThe following was present:<\/p>\n
\n- 10- 12 errors in APA format<\/li>\n<\/ul>\n
AND\/OR<\/p>\n
\n- Responses have 8-9 grammatical, spelling and punctuation errors<\/li>\n<\/ul>\n
AND\/OR<\/p>\n
\n- Writing style is not focused on topic, making discussion difficult to understand.<\/li>\n<\/ul>\n<\/td>\n
<\/p>\nThe following was present:<\/p>\n
\n- 13 – 15 errors in APA format<\/li>\n<\/ul>\n
AND\/OR<\/p>\n
\n
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.<\/p>\n
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.<\/p>\n
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.<\/p>\n
Analyze the missed steps or protocol deviations related to an adverse event or near miss.<\/p>\n
Describe how the event resulted from a patient\u2019s medical management<\/a> rather than from the underlying condition.<\/p>\n Identify and evaluate the missed steps or protocol deviations that led to the event.<\/p>\n Discuss the extent to which the incident was preventable.<\/p>\n Research the impact of the same type of adverse event or near miss in other facilities.<\/p>\n Analyze the implications of the adverse event or near miss for all stakeholders.<\/p>\n 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.<\/p>\n Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis<\/strong><\/a><\/span><\/p>\n Analyze the responsibilities and actions of the inter-professional team. Explain what measures should have been taken and identify<\/p>\n the responsible parties or roles.<\/p>\n Describe any change to process or protocol implemented after the incident.<\/p>\n Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.<\/p>\n Analyze the quality improvement technologies that were put in place to increase patient safety and prevent a repeat of similar events.<\/p>\n Determine whether the technologies are being utilized appropriately.<\/p>\n Explore how other institutions integrated solutions to prevent these types of events.<\/p>\n Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.<\/p>\n Identify the salient data that is associated with the adverse event or near miss that is generated from the facility\u2019s 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<\/a>.)<\/p>\n Analyze what the relevant metrics show.<\/p>\n 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.<\/p>\n Outline a quality improvement initiative to prevent a future adverse event or near miss.<\/p>\n Explain how the process or protocol is now managed and monitored in your facility.<\/p>\n Evaluate how other institutions addressed similar incidents or events.<\/p>\n Analyze QI initiatives developed to prevent similar incidents, and explain why they are successful. Provide evidence of their success.<\/p>\n Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.<\/p>\n Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.<\/p>\n Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.<\/p>\n Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. The process of QI and ensuring patient safety is challenging because health care Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited.<\/p>\n Agency for Healthcare Research and Quality. (2015a). Prevention quality indicators. Retrieved Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. Copyright \u00a92017 Capella University. Copy and distribution of this document are prohibited. 100%<\/strong><\/p>\n 16 points<\/strong><\/td>\n 88%<\/strong><\/p>\n 14 points<\/strong><\/td>\n 81%<\/strong><\/p>\n 13 points<\/strong><\/td>\n 68%<\/strong><\/p>\n 11 points<\/strong><\/td>\n 56%<\/strong><\/p>\n 9 points<\/strong><\/p>\n \u00a0<\/strong><\/td>\n of performance<\/strong><\/p>\n 55% or less<\/strong><\/p>\n 0 points<\/strong><\/td>\n<\/tr>\n<\/thead>\n\n Demonstrates achievement of scholarly inquiry for professional and academic topics.<\/td>\n Presentation of information is unsatisfactory in one<\/strong> of the following elements:<\/p>\n Presentation of information is unsatisfactory in two<\/strong> of the following elements:<\/p>\n Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations<\/strong><\/td>\n Initial post should be a minimum of 300 words (references do not count toward word count)<\/strong><\/p>\n The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count)<\/strong><\/p>\n Responses are substantive and relate to the topic.<\/strong><\/td>\n Points deducted for improper grammar, syntax and APA style of writing.<\/strong><\/p>\n The source of information is the APA Manual 6th Edition<\/strong><\/p>\n Error is defined to be a unique APA error. Same type of error is only counted as one error.<\/strong><\/td>\n AND<\/p>\n AND<\/p>\n AND\/OR<\/p>\n AND\/OR<\/p>\n AND\/OR<\/p>\n AND\/OR<\/p>\n The following was present:<\/p>\n AND\/OR<\/p>\n AND\/OR<\/p>\n The following was present:<\/p>\n AND\/OR<\/p>\nRunning head: ADVERSE EVENT OR NEAR MISS ANALYSIS 1<\/h3>\n
\nAdverse Event or Near Miss Analysis
\nLearner\u2019s Name
\nCapella University
\nQuality Improvement for Interprofessional Care
\nAdverse Event or Near Miss Analysis
\nJuly, 2017
\nComment [JS1]: This submission is
\nvery well crafted according to the
\nrubric. The submission is written in a
\nscholarly voice and free of APA and
\ngrammatical errors.<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 2<\/h3>\n
\nAdverse Event or Near Miss Analysis
\nPreventable adverse events are among the top causes of death in the United States.
\nEstimates reveal that 210,000 to 400,000 fatal adverse events occur every year (Allen, 2013).
\nExamples of preventable adverse events are hospital-acquired diseases, medication errors, and
\npatient falls. The focus of this adverse event analysis is medication errors, also known as adverse
\ndrug events (ADEs), such as medication overdoses or administration of wrong medicines. The
\nanalysis will recommend strategies to mitigate ADEs based on a case of medication overdose
\nobserved in the emergency department (ED) at TrueWill General Hospital (TGH), a
\nmultispecialty hospital in the United States.
\nA 40-year-old woman was brought to the ED after suffering a seizure. Before she was
\ndischarged, she suffered another seizure and the ED doctor prescribed 800 mg of phenytoin, an
\nanti-seizure medication, to be given intravenously (IV). The ED nurse misread the prescribed
\ndosage in the electronic medical record (EMR) and administered 8000 mg, which was 10-fold
\ngreater than the prescribed dosage. The patient died soon after the lethal infusion (Manias, 2012).
\nThe incident shows that the nurse made a series of cognitive errors in medication
\nmanagement and missed key steps (Manias, 2012), which will be explained in the analysis
\nreport. Additionally, the analysis will examine the implications of adverse events on multiple
\nstakeholders. Relevant evidence and metrics will be incorporated when making suggestions for
\nimprovement of patient safety at TrueWill General Hospital.
\nAnalysis of Missed Steps Related to the Adverse Event
\nEmergency departments are susceptible to adverse events because of the unscheduled
\nnature of patient presentation, urgency, and severity of cases. In such high-pressure situations,<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 3<\/h3>\n
\nclinicians must be more careful when treating a patient (Manias, 2012). Retracing the steps taken
\nby the nurse revealed several missed steps in the delivery of care.
\nTo begin with, the drug dispensing machines in the ED were stocked with phenytoin in
\n250 mg vials; the correct dose required only 3.2 vials. As the nurse had misread the dose, she
\nneeded 32 vials of the drug. She took the vials from three different drug dispensers and
\nadministered the dose using two IV bags as well as a piggyback line (Manias, 2012). The nurse
\ndid not question the difficulty in procuring and administering the drugs; nor did she ask anyone
\nto validate her calculations. Furthermore, she was not asked why she was removing so many
\nvials from the drug dispensers in the ED unit.
\nThe scenario also shows that the nurse was unaware of the toxic nature of phenytoin
\nwhen administered in large quantities; she was unable to recognize the warning signs.
\nAdditionally, the fact that the nurse could remove 32 vials is evidence of the technical drawbacks
\nof the automated drug dispensing machines. The machines were not programed to send out alerts
\nwhen large quantities of medications, especially high-alert medication like phenytoin, were
\ndispensed (Manias, 2012). They were also not synced to the patient\u2019s medical record. Therefore,
\nthe machines contained no information on drug preparation or correct dosages and did not
\ndisplay any warning signs.
\nVarious systems factors such as communication, leadership, education, training, and
\ninnovation of health care technology influenced the ED nurse\u2019s clinical performance. The factors
\noriginate from the adaptation of systems theory into health care (Huber, 2017). There are,
\nhowever, areas of uncertainty regarding the factors becoming problematic in TGH\u2019s scenario. For
\nexample, the nurse\u2019s hesitation to consult her team could have been caused by staff management
\nproblems such as conflict, overwork, or shortage of ED staff. Similarly, her lack of awareness of<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 4<\/h3>\n
\ndosages and safety measures shows gaps in education and training. Such problems are a result of
\na breakdown of systems factors. Further evaluation is essential to understand the root causes of
\nadverse events and systems problems. Ignoring root causes can result in similar adverse events in
\nthe future and negatively impact the stakeholders.
\nImplications of the Adverse Event on Stakeholders
\nSince medicine is a profession that depends on interpersonal relationships, adverse events
\nhave unintended emotional, psychological, and professional consequences on all stakeholders.
\nPatients and their families are the first victims of adverse events, while health care professionals
\nand the organization become the second and third victims, respectively (Mira et al., 2015). A
\nsimilar inference can be made about the adverse event at TGH; the inference is supported by
\ncertain assumptions about the health care environment. General assumptions about health care
\nare as follows: (a) quality health care is a result of positive relationships between all stakeholders
\n(Huber, 2017), (b) stakeholders are part of a high-risk environment where errors in clinical
\npractice are common, (c) health care professionals are not always responsible for errors as errors
\nare often caused by a breakdown in systems factors (Manias, 2012), and (d) errors diminish the
\nmorale and job satisfaction of health care professionals and lead to more adverse events (Huber,
\n2017).
\nThe analysis of implications on stakeholders begins with identifying how each category
\nof victims is impacted. The first victims expect hospital stays and procedures to be safe and
\nbeneficial. When a patient suffers an injury, or dies because of medical negligence, the family
\nmay feel aggrieved and may require counseling and support. They may feel unnerved and scared
\nby health care professionals (Bernhard, 2013) and hesitate to seek medical treatment in the
\nfuture. The study reported that health care professionals were traumatized after committing a<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 5<\/h3>\n
\npreventable error or witnessing an adverse event. They may lose confidence, abandon their
\ncareers (Bernhard, 2013), and experience anxiety or depression (Mira et al., 2015). Adverse
\nevents are damaging to careers, and nursing professionals may face difficulty in finding another
\njob (Bernhard, 2013).
\nAdverse events also affect the organization\u2014the third victim\u2014by damaging its
\nreputation. Adverse events can discourage people from seeking treatment at a particular hospital
\n(Mira et. al, 2015). Moreover, as most preventable errors are not covered by Medicaid and
\nMedicare services, the hospital can stand to lose a significant amount of reimbursement money.
\nIt is important that health care organizations such as TGH find ways to minimize the
\nimpact of adverse events on different stakeholders. The current trend in quality improvement
\n(QI) is focused on reducing human errors through automation of health care technologies. In the
\ncase of TGH, the existing level of automation of patient records and drug dispensers is not
\nsufficient and needs to be replaced. The next section recommends and discusses the benefits of a
\npopular QI technology\u2014patient care dashboards.
\nEvaluation of Quality Improvement Technologies
\nPerformance measurement and reporting by health care professionals are the crux of QI
\nbecause transmitting, organizing, analyzing, and displaying performance data help in identifying
\nareas that need improvement (Ghazisaeidi, 2015). A recent development in QI technologies is the
\nintroduction of visual dashboards. Dashboards are interactive performance management tools
\nthat use graphic and easy-to-use formats to present specific metrics or key performance
\nindicators (KPIs) on a single computer screen (Ghazisaeidi, 2015). Implementing a dashboard
\ncan help TGH improve quality of care and patient safety.<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 6<\/h3>\n
\nStudies show that the use of data-driven dashboards improves patient safety and
\naccelerates cost reduction efforts. A dashboard reduces human errors in processes and minimizes
\nthe cognitive effort needed to make decisions, thereby saving time and increasing efficiency and
\naccuracy. The KPIs aggregate data collected from various sources. For example, clinical data
\nincorporated into a dashboard include patient information gathered from physician or nurse
\ncharts. A dashboard can also consolidate metrics about market dynamics, innovation for long\u0002term sustainability, and availability of financial and human resources for managers to analyze
\n(Weiner, Balijepally, & Tanniru, 2015).
\nTo help TGH efficiently customize the dashboard to its specific clinical context, the tool
\nshould be tested and evaluated using certain criteria. The categories for each criterion are as
\nfollows: (a) easy customization, (b) knowledge discovery, (c) security, (d) information delivery,
\n(e) visual design, (f) alerts, and (g) system connectivity and integration (Karami, 2014). These
\ncriteria can be used for all types of dashboards and health care settings.
\nWhile the design features are important, the dashboard is only useful if the KPIs provide
\nvaluable data. Hence, the selection and development of KPIs are critical steps in QI at TGH
\nwithout which the organization runs the risk of ignoring areas that require corrective action
\n(Ghazisaeidi, 2015).
\nRelevant Metrics of Quality Improvement for TrueWill General Hospital
\nThe KPIs are the most valuable content in a dashboard. They measure performance
\nacross the organization using a combination of administrative and clinical data sets. To prevent
\noverloading the electronic dashboard, only a limited number of KPIs concerning high-priority
\nareas are selected. These KPIs are based on evidence-based academic literature. Data for each
\nKPI is sourced from different source systems in the organization such as accounting system,<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 7<\/h3>\n
\nhuman resources system, and clinical system (Ghazisaeidi, 2015). For example, clinical data are
\nsourced from reports on whether clinicians treated the correct patient, addressed the equipment
\nor supplies needs, prescribed the correct medication or anesthesia at the appropriate time, and
\ndetected patient allergies (Hagland, 2012). For the adverse event analysis report, the relevant
\nKPIs will focus on clinical and patient-centric metrics.
\nHealth care agencies such as the Agency for Healthcare Research and Quality (AHRQ)
\nhave developed their own sets of metrics that address various aspects of quality\u2014patient safety,
\nprevention quality, inpatient quality, and pediatric quality. TGH can customize its clinical and
\npatient-centric KPIs for the dashboard from these aspects. Examples of relevant AHRQ metrics
\nthat are applicable to the ED adverse event include (a) death rate in low-mortality diagnosis
\nrelated groups, (b) accidental puncture or laceration rate, (c) heart failure mortality rate, and (d)
\ndehydration admission rate (AHRQ, 2015a, 2015b, 2015c).
\nThe ED department at THG can include other relevant KPIs in the dashboard such as (a)
\nmonthly averages for patient length of stay (inpatient and outpatient); (b) patients in the ED who
\nleft without being seen (monthly); (c) radiology test (CT scan and x-ray), start to final dictation
\nturnaround time (Weiner, Balijepally, & Tanniru, 2015); (d) speed of onset of pain relief; (e) cost
\nreduction percentage per patient; and (f) risk of drug interactions (Dolan, Veazie, & Russ, 2013).
\nThe evidence-base for the selected KPIs consists of peer-reviewed studies. Hagland
\n(2012) proved the success of the dashboard for patient safety optimization at the Saint Luke\u2019s
\nMid America Heart Institute, Missouri. The dashboard increased communication within medical
\nteams, reduced safety errors, and improved coordination between the teams. Dolan, Veazie, and
\nRuss (2013) studied the effectiveness of the electronic dashboard as a decision-making tool. The
\nresults showed that the dashboard had potential to foster informed decision-making and patient-<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 8<\/h3>\n
\ncentered care. Weiner, Balijepally, and Tanniru (2015) studied the integration of data-driven
\ndashboards at the St. Joseph Mercy Oakland Hospital in Michigan. The study reported tangible
\nbenefits such as KPIs reporting reduced adverse event rates and intangible benefits such as
\nincreased accountability across the organization, self-improvement among nurses, and improved
\nunit performance.
\nThe dashboard is just the technological component of quality improvement. TGH
\nrequires a broader QI framework that incorporates organizational strategies to overcome
\nproblems in the ED that resulted in the death of the patient. A suitable framework will be selected
\nafter evaluating different perspectives and data about quality improvement.
\nOutline for a Quality Improvement Initiative for TrueWill General Hospital
\nThe health care industry has adopted and adapted many QI and measurement models over
\nthe years. Two popular models in quality improvement are the six sigma and lean models. Both
\nmodels have similar goals\u2014eliminate operational waste and defects to improve quality and
\nefficiency of a system. The main difference between the six sigma and lean is in the approaches
\nto identifying the cause of defects and errors. According to six sigma, variations in processes
\ncause errors, while lean thinking highlights unnecessary steps as the cause of operational waste
\nand errors (AHRQ, 2017).
\nAs both process variations and unnecessary steps can cause errors, the combination of the
\nlean and six sigma models can be implemented at TGH as its quality improvement outline. The
\nhospital can follow the lean six sigma model\u2019s DMAIC approach. DMAIC is a five-step
\napproach to process improvement: (a) define\u2014identify key business issues; (b) measure\u2014
\nunderstand current levels of performance; (c) analyze\u2014identify root causes of process errors; (d)
\nimprove\u2014introduce strategies and tools to improve quality of process; and (e) control\u2014maintain<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 9<\/h3>\n
\nnew levels of performance across the organization (Huber, 2017). Implementing the lean six
\nsigma into all units and departments, not just the ED, at TGH will help streamline processes in a
\nproactive manner. By improving the whole system, the hospital can prevent communication gaps
\nor errors, disorganization, and breakdown of faulty systems. DMAIC steps will allow TGH to
\nenhance QI process using tools and strategies such as the dashboard.
\nThe Institute of Health Improvement\u2019s plan-do-study-act (PDSA) model and the Baldrige
\ncriteria were other quality improvement perspectives that were considered (Huber, 2017).
\nHowever, the PDSA insufficiently addressed specific types of errors caused by variations or
\nunnecessary steps, unlike the lean six sigma model. The Baldrige criteria too were insufficient
\nbecause their usage was more suitable for enabling educational excellence. Additionally, there is
\nextensive evidence supporting the lean and six sigma models in quality improvement.
\nWhile the lean six sigma model and dashboards have a high success-rate, implementing
\nthe QI initiative depends on coordinated and collaborative efforts by multiple stakeholders.
\nTeamwork enables TGH\u2019s health care professionals to optimize systems factors and the quality
\nof processes and prevent future adverse events.<\/p>\nMSN 6016 Assessment 1\u00a0 Adverse Event or Near Miss Analysis <\/em><\/strong>Conclusion<\/h3>\n
\norganizations must simultaneously provide the highest quality of services and introduce cost
\nreduction strategies. Quality improvement initiatives, such as implementing dashboards, must
\nfocus on finding and fixing the root causes of errors or process inefficiencies. To identify the root
\ncauses of errors, the organization should train health care professionals, update health care
\ntechnologies, and open lines of communication to meet the expectations of patients for safe,
\ntimely, affordable, and quality care.<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 10<\/h3>\n
MSN 6016 Assessment 1\u00a0 Adverse Event or Near Miss Analysis <\/em><\/strong>References<\/h3>\n
\nfrom https:\/\/qualityindicators.ahrq.gov\/Downloads\/Modules\/PQI\/V50\/PQI_Brochure.pdf<\/a>
\nAgency for Healthcare Research and Quality. (2015b). Patient safety indicators. Retrieved from
\nhttps:\/\/qualityindicators.ahrq.gov\/Downloads\/Modules\/PSI\/V50\/PSI_Brochure.pdf<\/a>
\nAgency for Healthcare Research and Quality. (2015c). Inpatient quality indicators. Retrieved
\nfrom https:\/\/qualityindicators.ahrq.gov\/Downloads\/Modules\/IQI\/V50\/IQI_Brochure.pdf<\/a>
\nAgency for Healthcare Research and Quality. (2017). Section 4: Ways to approach the quality
\nimprovement process. In The CAHPS ambulatory care improvement guide: Practical
\nstrategies for improving patient experience. Retrieved from
\nhttps:\/\/ahrq.gov\/cahps\/quality-improvement\/improvement-guide\/4-approach-qi\u0002process\/sect4part2.html#4c<\/a>
\nAllen, M. (2013, September 19). How many die from medical mistakes in U.S. hospitals?
\n[Ongoing investigative report]. ProPublica. Retrieved from
\nhttps:\/\/propublica.org\/article\/how-many-die-from-medical-mistakes-in-us-hospitals<\/a>
\nBernhard, B. (2013, May 5). Medical errors leave devastating impact on families, professionals.
\nSt. Louis Post-Dispatch. Retrieved from http:\/\/stltoday.com\/lifestyles\/health-med\u0002fit\/health\/medical-errors-leave-devastating-impact-on-families\u0002professionals\/article_0cb6f031-fbc6-5b8f-bed9-610163dbf2f8.html<\/a>
\nDolan, J. G., Veazie, P. J., & Russ, A. J. (2013). Development and initial evaluation of a
\ntreatment decision dashboard. BMC Medical Informatics and Decision Making, 13(1), 51.
\nRetrieved from https:\/\/search-proquest-com.library.capella.edu\/docview\/1347649264?pq\u0002origsite=summon<\/a><\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 11<\/h3>\n
\nHagland, M. (2012). A dashboard for OR patient safety optimization. Healthcare
\nInformatics, 29(8), 29\u201331. Retrieved from https:\/\/search-proquest\u0002com.library.capella.edu\/docview\/1038458450?pq\u0002origsite=summon&http:\/\/library.capella.edu\/login%3furl=accountid=27965
\nHuber, D. L. (2017). Leadership and nursing care management (6th ed.) Philadelphia: W.B.
\nSaunders. http:\/\/dx.doi.org\/10.7748\/nm.21.6.13.s14<\/a>
\nGhazisaeidi, M., Safdari, R., Torabi, M., Mirzaee, M., Farzi, J., & Goodini, A. (2015).
\nDevelopment of performance dashboards in healthcare sector: Key practical issues. Acta
\nInformatica Medica, 23(5), 317\u2013321. Retrieved from https:\/\/search-proquest\u0002com.library.capella.edu\/docview\/1727377974?pq-origsite=summon
\nKarami, M. (2014). A design protocol to develop radiology dashboards. Acta Informatica
\nMedica, 22(5), 341\u2013346. http:\/\/dx.doi.org\/10.5455\/aim.2014.22.341-346<\/a>
\nManias, E. (2012). Looking for meds in all the wrong places [Case study commentary].
\nRetrieved from https:\/\/psnet.ahrq.gov\/webmm\/case\/282\/looking-for-meds-in-all-the\u0002wrong-places?q=Looking+for+meds+in+all+the+wrong+place<\/a>
\nMira, J. J., Lorenzo, S., Carrillo, I., Ferr\u00fas, L., P\u00e9rez-P\u00e9rez, P., Iglesias, F.,\u2026 Astier, P. (2015).
\nInterventions in health organisations to reduce the impact of adverse events in second and
\nthird victims. BMC Health Services Research, 15(1), 341\u2013350. Retrieved from
\nhttps:\/\/search-proquest-com.library.capella.edu\/docview\/1780186926?<\/a>pq\u0002origsite=summon&http:\/\/library.capella.edu\/login%3furl=accountid=27965<\/a>
\nWeiner, J., Balijepally, V., & Tanniru, M. (2015). Integrating strategic and operational decision
\nmaking using data-driven dashboards: The case of St. Joseph Mercy Oakland
\nHospital. Journal of Healthcare Management, 60(5), 319\u2013331. Retrieved from
\nComment [JS2]: I would suggest
\nlocating a more current reference.
\nThis reference is on the cusp of being
\noutdated according to health care
\nresearch standards of being less than
\nfive years. With this topic, I am sure
\nthere are more updated references that
\ncould be used instead.
\nComment [JS3]: This is another
\nreference that should be updated for
\nthe above reasons.<\/p>\nADVERSE EVENT OR NEAR MISS ANALYSIS 12<\/h3>\n
\nhttps:\/\/search-proquest\u0002com.library.capella.edu\/docview\/1733617419?OpenUrlRefId=info:xri\/sid:summon&acco
\nuntid=27965<\/p>\nA Sample Answer For the Assignment: MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis<\/strong><\/h2>\n
Title: MSN 6016 Assessment 1: Adverse Event or Near Miss Analysis<\/strong><\/h2>\n
MSN 6016 Assessment 1\u00a0 Adverse Event or Near Miss Analysis <\/em>Grading Rubric<\/strong><\/h3>\n
\n\n
\n Performance Category<\/strong><\/td>\n 100% or highest level of performance<\/strong><\/p>\n Very good or high level of performance<\/strong><\/p>\n Acceptable level of performance<\/strong><\/p>\n Inadequate demonstration of expectations<\/strong><\/p>\n Deficient level of performance<\/strong><\/p>\n Failing level<\/strong><\/p>\n \n \u00a0Total Points Possible= 50 <\/strong><\/td>\n \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 16 Points<\/strong><\/td>\n \u00a0\u00a0 14 Points<\/strong><\/td>\n 13 Points<\/strong><\/td>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 11 Points<\/strong><\/td>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 9 Points<\/strong><\/td>\n \u00a0 \u00a0 \u00a0 \u00a0\u00a0 0 Points<\/strong><\/td>\n<\/tr>\n \n Scholarliness<\/strong><\/p>\n Presentation of information was exceptional and included all<\/strong> of the following elements:<\/p>\n \n
Presentation of information was good, but was superficial in places and included all of the following elements:<\/p>\n \n
Presentation of information was minimally demonstrated in all of the following elements:<\/p>\n \n
<\/p>\n \n
<\/p>\n \n
Presentation of information is unsatisfactory in three<\/strong> or more<\/strong> of the following elements<\/p>\n \n
\n <\/td>\n \u00a016 Points<\/strong><\/td>\n \u00a014 Points<\/strong><\/td>\n \u00a013 Points<\/strong><\/td>\n 11 Points<\/strong><\/td>\n 9 Points<\/strong><\/td>\n \u00a00 Points<\/strong><\/td>\n<\/tr>\n \n Application of Course Knowledge<\/strong><\/p>\n Presentation of information was exceptional and included all<\/strong> of the following elements:<\/p>\n \n
Presentation of information was good, but was superficial in places and included all<\/strong> of the following elements:<\/p>\n \n
Presentation of information was minimally demonstrated in the all<\/strong> of the following elements:<\/p>\n \n
Presentation of information is unsatisfactory in one <\/strong>of the following elements:<\/p>\n \n
Presentation of information is unsatisfactory in two<\/strong> of the following elements:<\/p>\n \n
Presentation of information is unsatisfactory in three<\/strong> of the following elements<\/p>\n \n
\n \u00a0<\/strong><\/td>\n \u00a010 Points<\/strong><\/td>\n 9 Points <\/strong><\/td>\n <\/td>\n <\/td>\n \u00a06 Points<\/strong><\/td>\n \u00a00 Points<\/strong><\/td>\n<\/tr>\n \n Interactive Dialogue <\/strong><\/p>\n Demonstrated all <\/strong>of the following:<\/p>\n \n
Demonstrated 3 of the following:<\/p>\n \n
<\/td>\n <\/td>\n Demonstrated 2 of the following:<\/p>\n \n
Demonstrated 1 or less of the following:<\/p>\n \n
\n \u00a0<\/strong><\/td>\n 8 Points<\/strong><\/td>\n 7 Points<\/strong><\/td>\n \u00a06 Points<\/strong><\/td>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 5 Points<\/strong><\/td>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 4 Points<\/strong><\/td>\n \u00a00 Points<\/strong><\/td>\n<\/tr>\n \n Grammar, Syntax, APA <\/strong><\/p>\n The following was present:<\/p>\n \n
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The following was present:<\/p>\n \n
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The following was present:<\/p>\n \n
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