NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

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Assessment 1: Adverse Event or Near-Miss Analysis
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Student Name
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Capella University
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Course Name
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Nov 8, 2023
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Adverse Event or Near-Miss Incident Analysis
Adverse events (AEs) or near-miss incidents are prevalent in healthcare settings. Adverse
events are defined as undesirable outcomes resulting from preventable actions or medical
interventions that compromise patient safety and well-being (Schwendimann et al., 2018).
Near-miss events are incidents that, if they had occurred, could have caused harm or injury to
the consumers (Yang & Liu, 2021). Research spanning 27 countries on six continents indicates
that approximately 10% of hospital patients experience adverse events, with 7.3% being
life-threatening, and 34-83% being preventable (Schwendimann et al., 2018). More than
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250,000 patients face adversities during treatment, resulting in over 100,000 deaths due to
care-related issues (Skelly et al., 2022).
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This analysis focuses on preventable falls in healthcare settings, particularly a case involving an
86-year-old patient, Michelle, who fell in the Cardiovascular (CV) step-down unit at Miami Valley
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Hospital in the United States during her postoperative recovery.
Analysis of the Missed Steps, Protocol Deviations, and
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Knowledge Gaps
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The study indicates that hospitalized patients, irrespective of their disease, are considered at
risk of falls according to risk assessment tools (LeLaurin & Shorr, 2019). Patients with recent
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cardiovascular incidents and the geriatric population, particularly post-operative, have an
elevated fall risk (Dworsky et al., 2021; Manemann et al., 2018). In Michelle's case, the frontline
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nurse, Kellyn, missed identifying the patient's fall risk score, indicating a knowledge gap and a
failure to prioritize tasks. Additionally, the nurse lacked awareness of the patient's environment
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and fall preventive measures. Nurse managers should establish policies to prevent protocol
deviations and maintain patient safety.
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The Morse Fall Scale (MFS), a globally accepted fall risk assessment tool, categorizes patients
into low, medium, and high-risk levels based on six criteria (Kim et al., 2021). Healthcare
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providers must enhance their knowledge of risk assessment skills to ensure patient safety.
Key missing information includes why Nurse Kellyn did not monitor her patients adequately, the
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actions of other healthcare providers, family inaction, and whether the patient was informed
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about fall risk prevention measures. Answers to these questions would aid in a more
comprehensive analysis of the root causes of the incident.
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Analysis of the Implications for the Stakeholders

Stakeholders, including patients, family members, nurses, and hospital administration, play
crucial roles in healthcare. Adverse events negatively impact patients and their families, and
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legal repercussions create a vulnerable environment for hospital administration. Negative
consequences include a decline in hospital reputation and poor healthcare quality (Baris &
Seren Intepeler, 2018).
Effective collaboration among stakeholders is essential for quality healthcare. All stakeholders
share responsibility for errors in medical practices and should work together to prevent adverse
events. Healthcare organizations, such as Miami Valley Hospital, must establish measures to
minimize adverse events and their impacts.
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Quality Improvement Actions and Technologies
Various fall prevention strategies and quality improvement actions are recommended, such as
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identifying at-risk patients, alarms, sitters, patient education, environmental modifications,
restraints, and non-slip socks (LeLaurin & Shorr, 2019). Portable video monitoring (PVM) during
nighttime is a technological intervention that has shown success in reducing falls (Woltsche et
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al., 2022).
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Evaluation metrics for these actions and technologies include comparisons of falls before and
after implementation, patient education, cost-effectiveness, ease of use for nurses, and nurse
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education (Morat et al., 2023; Montero-Odasso et al., 2021).
Outline for a Quality Improvement Initiative

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Lean Six Sigma (LSS) is a methodology that can enhance the capability and efficacy of
processes in healthcare settings. The DMAIC approach (Define, Measure, Analyze, Improve,
Control) is a five-step methodology to guide improvement efforts (Tufail et al., 2022).
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Quality improvement strategies may involve team changes, staff education, frequent audits and
feedback, and patient education (Tricco et al., 2019). The implementation of these strategies
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should be continuously monitored and sustained for long-term effectiveness.

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Conclusion
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Ensuring patient safety and quality improvement in healthcare is challenging but crucial. Quality
improvement initiatives, including the use of assessment tools, staff and patient education, and
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technological interventions, are essential for addressing the root causes of adverse events.
Effective collaboration among stakeholders and the implementation of these measures will
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contribute to improved patient safety and healthcare quality.
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References
Baris, V. K., & Seren Intepeler, S. (2018). Views of key stakeholders on the causes of Patient
Falls and Prevention Interventions: A qualitative study using the International Classification of
Functioning, disability, and health. Journal of Clinical Nursing, 28(3-4), 615–628.
https://doi.org/10.1111/jocn.14656
Dworsky, J. Q., Shellito, A. D., Childers, C. P., Copeland, T. P., Maggard-Gibbons, M., Tan, H.-J.,
Saliba, D., & Russell, M. M. (2021). Association of Geriatric events with perioperative outcomes
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after elective inpatient surgery. Journal of Surgical Research, 259, 192–199.
https://doi.org/10.1016/j.jss.2020.11.011
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Kim, Y. J., Choi, K. O., Cho, S. H., & Kim, S. J. (2021). Validity of the Morse fall scale and the
Johns Hopkins Fall Risk Assessment Tool for fall risk assessment in an acute care setting.
Journal of Clinical Nursing, 31(23-24), 3584–3594. https://doi.org/10.1111/jocn.16185
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Laird, Y., Manner, J., Baldwin, L., Hunter, R., McAteer, J., Rodgers, S., Williamson, C., &
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Jepson, R. (2020). Stakeholders’ experiences of the Public Health Research Process: Time to
change the system? Health Research Policy and Systems, 18(1).
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https://doi.org/10.1186/s12961-020-00599-5
LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients. Clinics in Geriatric
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Medicine, 35(2), 273–283. https://doi.org/10.1016/j.cger.2019.01.007
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López-Soto, P. J., López-Carrasco, J. de, Fabbian, F., Miñarro-Del Moral, R. M., Segura-Ruiz,
R., Hidalgo-Lopezosa, P., Manfredini, R., & Rodríguez-Borrego, M. A. (2021). Chronoprevention
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in Hospital Falls of Older people: Protocol for a mixed-method study. BMC Nursing, 20(1).
https://doi.org/10.1186/s12912-021-00618-y
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Manemann, S. M., Chamberlain, A. M., Boyd, C. M., Miller, D. M., Poe, K. L., Cheville, A.,
Weston, S. A., Koepsell, E. E., Jiang, R., & Roger, V. L. (2018). Fall risk and outcomes among
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patients hospitalized with cardiovascular disease in the community. Circulation: Cardiovascular

Quality and Outcomes, 11(8). https://doi.org/10.1161/circoutcomes.117.004199
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Montero-Odasso, M. M., Kamkar, N., Pieruccini-Faria, F., Osman, A., Sarquis-Adamson, Y.,
Close, J., Hogan, D. B., Hunter, S. W., Kenny, R. A., Lipsitz, L. A., Lord, S. R., Madden, K. M.,
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Petrovic, M., Ryg, J., Speechley, M., Sultana, M., Tan, M. P., van der Velde, N., Verghese, J., &
Masud, T. (2021). Evaluation of clinical practice guidelines on fall prevention and management
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for older adults. JAMA Network Open, 4(12), e2138911.

https://doi.org/10.1001/jamanetworkopen.2021.38911
Morat, T., Snyders, M., Kroeber, P., De Luca, A., Squeri, V., Hochheim, M., Ramm, P., Breitkopf,
A., Hollmann, M., & Zijlstra, W. (2023). Evaluation of a novel technology-supported fall
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prevention intervention – study protocol of a multi-center randomized controlled trial in older
adults at increased risk of falls. BMC Geriatrics, 23(1).
https://doi.org/10.1186/s12877-023-03810-8
Rathi, R., Vakharia, A., & Shadab, M. (2022). Lean Six Sigma in the healthcare sector: A
Systematic Literature Review. Materials Today: Proceedings, 50, 773–781.
https://doi.org/10.1016/j.matpr.2021.05.534
Skelly, C. L., Cassagnol, M., & Munakomi, S. (2022). Adverse events. In StatPearls. StatPearls
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Publishing. http://www.ncbi.nlm.nih.gov/books/NBK558963/
Schwendimann, R., Blatter, C., Dhaini, S., Simon, M., & Ausserhofer, D. (2018). The
occurrence, types, consequences, and preventability of in-hospital adverse events – a scoping
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review. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-3335-z
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Tufail, M. M., Shamim, A., Ali, A., Ibrahim, M., Mehdi, D., & Nawaz, W. (2022). DMAIC
methodology for achieving public satisfaction with health departments in various districts of
Punjab and optimizing CT scan patient load in Urban City Hospitals. AIMS Public Health, 9(2),
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440–457. https://doi.org/10.3934/publichealth.2022030
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Tricco, A. C., Thomas, S. M., Veronika, A. A., Hamid, J. S., Cogo, E., Strifler, L., Khan, P. A.,
Sibley, K. M., Robson, R., MacDonald, H., Riva, J. J., Thavorn, K., Wilson, C., Holroyd-Leduc,
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J., Kerr, G. D., Feldman, F., Majumdar, S. R., Jaglal, S. B., Hui, W., & Straus, S. E. (2019).
Quality Improvement Strategies to prevent falls in older adults: A systematic review and network
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meta-analysis. Age and Ageing, 48(3), 337–346. https://doi.org/10.1093/ageing/afy219
Yang, Y., & Liu, H. (2021). The effect of patient safety culture on nurses’ near-miss reporting
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intention: The moderating role of perceived severity of near misses. Journal of Research in
Nursing, 26(1-2), 6–16. https://doi.org/10.1177/1744987120979344
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Woltsche, R., Mullan, L., Wynter, K., & Rasmussen, B. (2022). Preventing patient falls overnight
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using video monitoring: A clinical evaluation. International Journal of Environmental Research

and Public Health, 19(21), 13735. https://doi.org/10.3390/ijerph192113735
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Assessment 1: Adverse Event or Near-Miss Analysis

Analysis of the Missed Steps, Protocol Deviations, and

Analysis of the Implications for the Stakeholders

Outline for a Quality Improvement Initiative

should be continuously monitored and sustained for long-term effectiveness.

contribute to improved patient safety and healthcare quality.

patients hospitalized with cardiovascular disease in the community. Circulation: Cardiovascular

for older adults. JAMA Network Open, 4(12), e2138911.

meta-analysis. Age and Ageing, 48(3), 337–346. https://doi.org/10.1093/ageing/afy219

using video monitoring: A clinical evaluation. International Journal of Environmental Research

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