NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis

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NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis – Step-by-Step Guide

The first step before starting to write the NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis, it is essential to understand the requirements of the assignment. The first step is to read the assignment prompt carefully to identify the topic, the length and format requirements. You should go through the rubric provided so that you can understand what is needed to score the maximum points for each part of the assignment. 

It is also important to identify the audience of the paper and its purpose so that it can help you determine the tone and style to use throughout. You can then create a timeline to help you complete each stage of the paper, such as conducting research, writing the paper, and revising it to avoid last-minute stress before the deadline. After identifying the formatting style to be applied to the paper, such as APA, you should review its use, such as writing citations and referencing the resources used. You should also review how to format the title page and the headings in the paper.

How to Research and Prepare for NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis

The next step in preparing for your paper is to conduct research and identify the best sources to use to support your arguments. Identify the list of keywords from your topic using different combinations. The first step is to visit the university library and search through its database using the important keywords related to your topic. You can also find books, peer-reviewed articles, and credible sources for your topic from PubMed, JSTOR, ScienceDirect, SpringerLink, and Google Scholar. Ensure that you select the references that have been published in the last words and go through each to check for credibility. Ensure that you obtain the references in the required format, for example, in APA, so that you can save time when creating the final reference list. 

You can also group the references according to their themes that align with the outline of the paper. Go through each reference for its content and summarize the key concepts, arguments and findings for each source. You can write down your reflections on how each reference connects to the topic you are researching about. After the above steps, you can develop a strong thesis that is clear, concise and arguable. Next you should create a detailed outline of the paper so that it can help you to create headings and subheadings to be used in the paper. Ensure that you plan what point will go into each paragraph.

How to Write the Introduction for NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis

The introduction of the paper is the most crucial part as it helps to provide the context of your work, and will determine if the reader will be interested to read through to the end. You should start with a hook, which will help capture the reader’s attention. You should contextualize the topic by offering the reader a concise overview of the topic you are writing about so that they may understand its importance. You should state what you aim to achieve with the paper. The last part of the introduction should be your thesis statement, which provides the main argument of the paper.

How to Write the Body for NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis

The body of the paper helps you to present your arguments and evidence to support your claims. You can use headings and subheadings developed in the paper’s outline to guide you on how to organize the body. Start each paragraph with a topic sentence to help the reader know what point you will be discussing in that paragraph. Support your claims using the evidence conducted from the research, ensure that you cite each source properly using in-text citations. You should analyze the evidence presented and explain its significance and how it connects to the thesis statement. You should maintain a logical flow between each paragraph by using transition words and a flow of ideas.

How to Write the In-text Citations for NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis

In-text citations help the reader to give credit to the authors of the references they have used in their works. All ideas that have been borrowed from references, any statistics and direct quotes must be referenced properly. The name and date of publication of the paper should be included when writing an in-text citation. For example, in APA, after stating the information, you can put an in-text citation after the end of the sentence, such as (Smith, 2021). If you are quoting directly from a source, include the page number in the citation, for example (Smith, 2021, p. 15). Remember to also include a corresponding reference list at the end of your paper that provides full details of each source cited in your text. An example paragraph highlighting the use of in-text citations is as below:

The integration of technology in nursing practice has significantly transformed patient care and improved health outcomes. According to Smith (2021), the use of electronic health records (EHRs) has streamlined communication among healthcare providers, allowing for more coordinated and efficient care delivery. Furthermore, Johnson and Brown (2020) highlight that telehealth services have expanded access to care, particularly for patients in rural areas, thereby reducing barriers to treatment.

How to Write the Conclusion for NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis

When writing the conclusion of the paper, start by restarting your thesis, which helps remind the reader what your paper is about. Summarize the key points of the paper, by restating them. Discuss the implications of your findings and your arguments. End with a call to action that leaves a lasting impact on the reader or recommendations.

How to Format the Reference List for NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis

The reference helps provide the reader with the complete details of the sources you cited in the paper. The reference list should start with the title “References” on a new page. It should be aligned center and bolded. The references should be organized in an ascending order alphabetically and each should have a hanging indent. If a source has no author, it should be alphabetized by the title of the work, ignoring any initial articles such as “A,” “An,” or “The.” If you have multiple works by the same author, list them in chronological order, starting with the earliest publication. 

Each reference entry should include specific elements depending on the type of source. For books, include the author’s last name, first initial, publication year in parentheses, the title of the book in italics, the edition (if applicable), and the publisher’s name. For journal articles, include the author’s last name, first initial, publication year in parentheses, the title of the article (not italicized), the title of the journal in italics, the volume number in italics, the issue number in parentheses (if applicable), and the page range of the article. For online sources, include the DOI (Digital Object Identifier) or the URL at the end of the reference. An example reference list is as follows:

References

Johnson, L. M., & Brown, R. T. (2020). The role of telehealth in improving patient outcomes. Journal of Nursing Care Quality, 35(2), 123-130. https://doi.org/10.1097/NCQ.0000000000000456

Smith, J. A. (2021). The impact of technology on nursing practice. Health Press.

NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis Instructions

  • Prepare an analysis (5-7 pages) of an adverse event or a near miss from your professional nursing experience and outline a QI initiative that would address it.

Introduction

Health care organizations strive to create a culture of safety. Despite technological advances, quality care initiatives, oversight, ongoing education and training, legislation, and regulations, medical errors continue to be made. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. Many errors are attributable to ineffective interprofessional communication.

Overview

The goal of this assessment is to allow you to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a QI initiative to prevent future incidents. It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself in as a health care professional.

Health care organizations strive for a culture of safety. Yet, despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation, and regulations, medical errors continue to occur. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. Have a look at NURS-FPX6016 Assessment 2 Quality Improvement Initiative Evaluation.

Historically, medical errors were reported and analyzed in hindsight. Today, QI initiatives attempt to be proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by new technologies and reporting metrics, adverse events and near misses can provide insight into potential ways to improve care delivery and ensure patient safety.

For clarification, the National Quality Forum (n.d.) defines the following:

  • Adverse event: An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.
  • Near miss: An event or a situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention.

Instructions

Prepare a comprehensive analysis of an adverse event or a near miss from your professional nursing experience that you or a peer experienced. Provide an analysis of the impact of the same type of adverse event or near miss in other facilities. How was it managed, who was involved, and how was it resolved? Be sure to:

  • Analyze the implications of the adverse event or near miss for all stakeholders.
  • Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.
  • Evaluate QI actions or technologies related to the event that are required to reduce risk and increase patient safety.
  • Evaluate how other institutions integrated solutions to prevent these types of events.
  • Incorporate relevant metrics of the adverse event or near miss to support need for improvement.
  • Outline a QI initiative to prevent a future adverse event or near miss.
  • Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Be sure your analysis addresses all of the above points. You may also want to read the Adverse Event or Near Miss Analysis Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Adverse Event or Near Miss Analysis [DOCX] document for additional clarification about things to consider when creating your assessment.

Additional Requirements

Your assessment should also meet the following requirements:

  • Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page or References section.
  • Number of references: Cite a minimum of three sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master’s Program (MSN) Library Guide for guidance.
  • APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.
Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

  • Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.
  • Analyze the implications of an adverse event or a near miss for all stakeholders.
  • Analyze the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis.
  • Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.
  • Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
  • Evaluate and identify quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.
  • Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
  • Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Reference

National Quality Forum. (n.d.). NQF patient safety terms and definitions. http://www.qualityforum.org/Topics/Safety_Definitions.aspx

NURS-FPX6016 Assessment 1 Adverse Event or Near-Miss Analysis Example

Adverse Event or Near Miss Analysis

To promote patient welfare, healthcare organizations work tirelessly to foster a safety culture. Nevertheless, medical errors remain common despite technological improvements, efforts to improve patient care, and continued education and training. These mistakes may result in severe consequences for patients and their loved ones and significant legal repercussions. Ineffective interprofessional communication is one of the primary causes of medical errors (Khan & Tidman, 2022). In this situation, the assessment aims to examine a specific incident in a healthcare setting, influence patient safety, and suggest a quality improvement (QI) project to stop similar occurrences.

A 40-year-old man with end-stage renal disease (ESRD) who was receiving chronic hemodialysis and overdosed on oxycodone and gabapentin due to improper medication management is the subject of the case study in question. We explore pain control, gabapentin toxicity among individuals with renal dysfunction, alert tiredness associated with clinical decision support, and methods to lessen adverse events brought on by drug-disease interactions. By fostering analytical abilities and problem-solving situations, this examination will benefit healthcare personnel by enhancing patient safety and reducing the likelihood of future medical blunders.

Implications to all stakeholders

More often than not, near misses and adverse events affect most, if not all, involved individuals. All parties concerned will be impacted significantly if a patient with end-stage renal disease (ESRD) takes too much oxycodone and gabapentin. The adverse occurrence in this instance serves as a warning about the risks of medication errors and drug-disease interactions, with both short- and long-term ramifications for the parties involved. Due to the patient using too much gabapentin and opiates, he developed severe metabolic encephalopathy, negatively impacting his health. Aside from the patient, the patient’s family may be financially and emotionally affected by the adverse event’s higher healthcare expenditures.

The interprofessional team, which includes the healthcare professionals in charge of the patient’s treatment, could have professional and legal repercussions that could harm their reputation and career prospects. The healthcare facility where the patient received treatment could be subject to legal and financial consequences, damaging its reputation and daily operations. The alarming event could cause the community to lose faith in the medical center and the healthcare system. Therefore, all involved parties might experience financial and legal consequences, affecting operations and people’s perceptions of them.

The interprofessional team must make sure that the patient’s safety comes first. They must act quickly to handle unfavorable events or near-misses and stop similar ones from happening. This includes notifying the proper authorities, doing a root cause analysis to determine the underlying causes of the occurrence, and creating a strategy to stop such incidents from happening again. To offer them support and to listen to their worries, the staff should also engage with the patient’s family.

Numerous precautions should have been taken for the gabapentin and oxycodone overdose in a patient with ESRD. The healthcare professionals in charge of the patient’s care should have been aware of the potential risks of drug-disease interactions (Zyoud et al., 2019). They should have taken the necessary procedures to prevent them. This can entail lowering pharmaceutical dosages in end-stage renal disease (ESRD) cases, keeping track of the patient’s renal function, and educating the patient and their family about the warning indications of gabapentin toxicity in those with renal dysfunction.

The healthcare professionals in charge of the patient’s care, the healthcare facility where the patient received treatment, and the regulatory bodies in charge of overseeing healthcare facilities and providers are all considered the responsible parties or roles in this situation. The occurrence might also alter how the parties involved carry out their duties, such as giving out medication, interacting with patients and their families, and reporting adverse events and near-misses.

Root Cause Analysis

Root cause analysis (RCA), a framework for identifying and treating the underlying causes of adverse events, can be used here. Martin-Delgado et al. (2020) state that RCA entails looking into the circumstances that resulted in the adverse event or near miss and figuring out the skipped stages or protocol deviations that contributed to the event. The following series of occurrences and missing steps can explain the 40-year-old man’s situation:

  • Regional nerve blocks, oral oxycodone, gabapentin, and other medications known to have adverse effects in patients with renal dysfunction were all used to address the patient’s postoperative pain (Horn & Kramer, 2020).
  • Despite having a pre-existing illness that made him more susceptible to adverse outcomes, the patient was not adequately watched for symptoms of toxicity or overdose.
  • The patient developed a severe metabolic encephalopathy because the medication doses were not changed to account for the patient’s ESRD.

The lack of communication and teamwork among the interprofessional team, along with a failure to adhere to set standards for prescribing and monitoring medicine in patients with ESRD, are among the missed steps or protocol violations that contributed to this chain of events. Kuitunen et al. (2020) stress the significance of addressing the underlying systemic causes of bad outcomes rather than holding particular healthcare professionals accountable for mistakes. The interprofessional team ought to have taken the following actions to avoid similar adverse events in the future:

  • Before prescribing and providing medication, a thorough evaluation of the patient’s medical history, present condition, and renal function was performed.
  • A pain management strategy that considers the patient’s pre-existing condition and risk factors for adverse outcomes was developed in collaboration with the patient and his family.
  • The patient constantly watched for any indications of toxicity or overdose, and his medication dosages were changed as necessary.
  • Promptly and successfully informed all interprofessional team members of the patient’s condition and any possible hazards related to his drug regimen.

The adverse event of the 40-year-old man with ESRD was somewhat avoidable because it was brought on by omitted steps and protocol violations that could have been corrected with better coordination, cooperation, and adherence to predetermined rules. Healthcare facilities can foster a safety culture and enhance patient outcomes by analyzing root causes and implementing evidence-based preventative measures.

Relative Quality Improved Measures

Several quality improvement technologies and techniques can be used to lower risk and improve patient safety associated with the adverse event of gabapentin and oxycodone overdose in a patient with end-stage renal disease (ESRD). Using electronic health records (EHRs) equipped with interruptive drug-disease alerts can aid in preventing prescription errors and adverse drug occurrences. Drug allergies, drug interactions, or medication duplications that could harm the patient are alerted to doctors via interruptive notifications (Bao & Bardhan, 2021). The interprofessional team could have adjusted the drug dosages in the patient with ESRD if interruptive warnings had alerted them to the possibility of gabapentin toxicity and opioid overdose.

Medication reconciliation is a crucial healthcare process that identifies and resolves patient medication history inconsistencies to ensure they receive the correct prescriptions at the proper doses. Failure to do so can lead to adverse events like medication toxicity or overdose. Drug reconciliation is finding and fixing patient drug history mistakes (Institute for Healthcare Improvement [IHI], 2020). This ensures that patients get the correct prescriptions at the right dose. Medication reconciliation should be done whenever a patient’s level of care changes, such as an admission, transfer, or discharge. Medication reconciliation in the case of the patient with ESRD might have revealed the patient’s medication history and demonstrated the possibility of gabapentin toxicity and opioid overdose because of the patient’s renal insufficiency.

Cooperation and interprofessional communication are crucial for reducing adverse outcomes and enhancing patient safety. Communication problems frequently result in drug errors and unfavorable effects in healthcare settings (Killin et al., 2021). It is essential to create a culture of safety that encourages honest and efficient communication among medical specialists. Therefore, to ensure the patient received safe and efficient pain management, the interprofessional team caring for the patient with ESRD should have examined the patient’s drug regimen and any hazards related to their renal dysfunction.

Healthcare institutions should continuously educate and train their employees on drug safety, medication reconciliation, and efficient interprofessional communication to ensure the proper application of quality improvement technologies and methods (IHI, 2020; Killin et al., 2021). Other institutions can prevent similar adverse outcomes by adopting interruptive drug-disease warnings, undertaking medication reconciliation at every transition of care, and encouraging efficient interprofessional communication.

Healthcare facilities can use their dashboard data to track patient safety indicators, including medication mistakes, adverse drug events, and readmission rates, to assess the efficacy of these quality improvement measures. Trending data can pinpoint problem areas and evaluate the results of activities for quality improvement. External data and research can also offer benchmarking data and recommended techniques for enhancing patient safety. Therefore, healthcare institutions should prioritize patient safety, foster effective communication among healthcare professionals, and provide their employees with continuing education and training on medication safety.

Quality improvement Initiative

A quality improvement effort should be implemented to stop future adverse events or near misses. The first stage is to form a multidisciplinary team that will be in charge of locating potential hazards and putting mitigation plans into action. Representatives from many areas, including nursing, medical, pharmacy, and administration, should be on the team. Then, implementing a uniform patient safety policy is a successful quality improvement strategy (Chaboyer et al., 2020). Regardless of a patient’s condition, the protocol should specify the procedures to guarantee they all receive the same high-quality care. This could involve regular safety inspections, medication rechecks, and fall protection techniques. The protocol should be evidence-based and evaluated regularly to stay current.  

Utilizing technology to promote patient safety is the core of the quality improvement strategy. For instance, implementing a barcode medicine administration system has significantly reduced medication errors (Mulac et al., 2021). Before the medication is given, this technology scans the patient’s wristband and the drug to ensure the patient is given the proper medication at the right time. The device also sends real-time alerts for possible medication errors, enabling medical professionals to act immediately. Therefore, successful, Evidence-based strategies include standardized patient safety measures and the use of technology to promote patient safety.

Regular audits and data analysis should be done to track the effectiveness of the quality improvement project. Analyzing incident reports, patient satisfaction tests, and clinical outcomes data may fall under this category. To pinpoint areas for improvement, it is also essential to regularly solicit feedback from patients and employees. Therefore, regular monitoring and evaluation of its performance are vital to guarantee that the initiative’s effectiveness endures over time.

Conclusion

Adverse occurrences and near-misses in healthcare affect patients, families, healthcare personnel, and facilities. Medical errors result from poor interprofessional communication. The 40-year-old man with end-stage renal disease who overdosed on oxycodone and gabapentin due to improper medication management shows the importance of taking precautions like medication dosage adjustment, monitoring patients for symptoms of toxicity or overdose, and educating patients and their families about warning signs.

Root cause analysis helps find and treat adverse event causes. The interprofessional team must prioritize patient safety, respond quickly to adverse events or near-misses, alert authorities, communicate with the patient’s family, and develop a plan to prevent repeat mishaps. Healthcare workers can improve patient safety and reduce medical errors by developing analytical and problem-solving skills.

References

Bao, C., & Bardhan, I. R. (2021). Performance of accountable care organizations: Health information technology and quality–efficiency trade-offs. Information Systems Research. https://doi.org/10.1287/isre.2021.1080

Chaboyer, W., Harbeck, E., Lee, B., & Grealish, L. (2020). Missed nursing care: An overview of reviews. The Kaohsiung Journal of Medical Sciences, 37(2), 82–91. https://doi.org/10.1002/kjm2.12308

Horn, R., & Kramer, J. (2020). Postoperative pain control. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544298/

Institute for Healthcare Improvement (IHI). (2020). Medication reconciliation review | IHI – institute for healthcare improvement. Www.ihi.org. https://www.ihi.org/resources/Pages/Tools/MedicationReconciliationReview.aspx

Khan, A., & Tidman, M. (2022). Causes of medication error in nursing-nc-nd license. JMRHS, 5(1), 1753–1764. http://jmrhs.info/index.php/jmrhs/article/download/511/610

Killin, L., Hezam, A., Anderson, K. K., & Welk, B. (2021). Advanced medication reconciliation: A systematic review of the impact on medication errors and adverse drug events associated with transitions of care. The Joint Commission Journal on Quality and Patient Safety, 47(7). https://doi.org/10.1016/j.jcjq.2021.03.011

Kuitunen, S., Niittynen, I., Airaksinen, M., & Holmström, A.-R. (2020). Systemic causes of in-hospital intravenous medication errors. Journal of Patient Safety, 17(8), 1. https://doi.org/10.1097/pts.0000000000000632

Martin-Delgado, J., Martínez-García, A., Aranaz-Andres, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How much of root cause analysis translates to improve patient safety. A systematic review. Medical Principles and Practice, 29(6). https://doi.org/10.1159/000508677

Mulac, A., Mathiesen, L., Taxis, K., & Gerd Granås, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223

Zyoud, S. H., Khaled, S. M., Kawasmi, B. M., Habeba, A. M., Hamadneh, A. T., Anabosi, H. H., Fadel, A. B., Sweileh, W. M., Awang, R., & Al-Jabi, S. W. (2019). Knowledge about the administration and regulation of high alert medications among nurses in Palestine: A cross-sectional study. BMC Nursing, 18(1). https://doi.org/10.1186/s12912-019-0336-0