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
Capella University
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Course Name
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Prof Name
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Feb 26, 2024
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Analysis of Adverse Events or Near-Miss Incidents in Healthcare Settings
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Adverse events (AEs) or near-miss incidents unfortunately occur frequently in healthcare
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environments, posing significant risks to patient safety. AEs are defined as undesirable
outcomes resulting from preventable actions or medical interventions that compromise patient
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well-being, while near-miss events are incidents that had the potential to cause harm but did not
result in injury. Research indicates that about 10% of hospitalized patients worldwide experience
adverse events, with a notable portion being preventable and potentially life-threatening.
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In this analysis, the focus is on preventable falls within healthcare settings, exemplified by a
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case involving an 86-year-old patient named Michelle who experienced a fall in the
Cardiovascular (CV) step-down unit during her postoperative recovery at Miami Valley Hospital
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in the United States.

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Analyzing Missed Steps, Protocol Deviations, and Knowledge Gaps
Hospitalized patients, especially those with recent cardiovascular incidents and the elderly, are
considered at elevated risk of falls. In Michelle's case, the frontline nurse failed to recognize the
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patient's fall risk score, indicating a knowledge gap and a failure to prioritize tasks. Additionally,
there was a lack of awareness regarding the patient's environment and fall preventive
measures. Nurse managers should establish policies to prevent protocol deviations and ensure
patient safety.
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The Morse Fall Scale (MFS), a globally recognized fall risk assessment tool, is crucial for
categorizing patients into low, medium, and high-risk levels. Healthcare providers must enhance
their risk assessment skills to ensure patient safety.
Key missing information includes why Nurse Kellyn did not adequately monitor her patients, the
actions of other healthcare providers, family involvement, and whether the patient was informed
about fall risk prevention measures. Obtaining answers to these questions is crucial for a
comprehensive analysis of the incident's root causes.
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Analyzing Implications for Stakeholders
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Stakeholders, including patients, family members, nurses, and hospital administration, play vital
roles in healthcare. Adverse events negatively impact patients and their families, potentially
leading to legal repercussions and a decline in hospital reputation and healthcare quality.
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Effective collaboration among stakeholders is essential for preventing adverse events and
minimizing their impacts.
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Quality Improvement Actions and Technologies
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Various fall prevention strategies and quality improvement actions are recommended, such as
identifying at-risk patients, implementing alarms, providing sitters, conducting patient education,
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making environmental modifications, using restraints cautiously, and providing non-slip socks.
Technological interventions like portable video monitoring (PVM) during nighttime have
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demonstrated success in reducing falls.
Evaluation metrics for these actions and technologies include comparisons of falls before and
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after implementation, effectiveness of patient education, cost-effectiveness, ease of use for

nurses, and nurse education.
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Outline for a Quality Improvement Initiative

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Lean Six Sigma (LSS) methodology, particularly the DMAIC approach (Define, Measure,
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Analyze, Improve, Control), can enhance the capability and efficacy of processes in healthcare
settings. Quality improvement strategies may involve team changes, staff education, frequent
audits and feedback, and patient education. Continuous monitoring and sustainability of these
strategies are crucial for long-term effectiveness.
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Conclusion
Ensuring patient safety and quality improvement in healthcare is paramount. Quality

improvement initiatives, including the use of assessment tools, staff and patient education, and
technological interventions, are essential for addressing the root causes of adverse events.
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Effective collaboration among stakeholders and the implementation of these measures will
contribute to improved patient safety and healthcare quality.
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References
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and Public Health, 19(21), 13735. https://doi.org/10.3390/ijerph192113735

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Assessment 1: Adverse Event or Near-Miss Analysis

in the United States.

Analyzing Missed Steps, Protocol Deviations, and Knowledge Gaps

demonstrated success in reducing falls.

after implementation, effectiveness of patient education, cost-effectiveness, ease of use for

Outline for a Quality Improvement Initiative

Ensuring patient safety and quality improvement in healthcare is paramount. Quality

Medicine, 35(2), 273–283. https://doi.org/10.1016/j.cger.2019.01.007

R., Hidalgo-Lopezosa, P., Manfredini, R., & Rodríguez-Borrego, M. A. (2021). Chronoprevention

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

and Public Health, 19(21), 13735. https://doi.org/10.3390/ijerph192113735

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