Discussion: Analysis on an Adverse Event

Discussion: Analysis on an Adverse Event

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Overview

Write a 5 page a comprehensive analysis on an adverse event or near miss from your professional nursing experience. Integrate research and data on the event and use as a basis to propose a quality improvement (QI) initiative in your current organization.

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.

The goal of this assessment is to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a quality improvement initiative to prevent future incidents.

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

· Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.

· Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.

· Competency 2: Plan quality improvement initiatives in response to routine data surveillance.

· Analyze the missed steps or protocol deviations related to an adverse event or near miss.

· Analyze the implications of the adverse event or near miss for all stakeholders.

· Outline a quality improvement initiative to prevent a future adverse event or near miss.

· Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.

· Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.

· Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.

· Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.

· Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

Assessment Instructions

Preparation

Prepare a comprehensive analysis on an adverse event or near-miss from your professional nursing experience that you or a peer experienced. Integrate research and data on the event and use as a basis to propose a Quality Improvement (QI) initiative in your current organization.

Note: Remember, you can submit all, or a portion of, your draft to Smarthinking for feedback, before you submit the final version of your analysis for this assessment. However, be mindful of the turnaround time for receiving feedback, if you plan on using this free service.

The numbered points below correspond to grading criteria in the scoring guide. The bullets below each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your Adverse Event or Near-miss Analysis addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels that relate to each grading criterion.

1. Analyze the missed steps or protocol deviations related to an adverse event or near miss.

· Describe how the event resulted from a patient’s medical management rather than from the underlying condition.

· Identify and evaluate the missed steps or protocol deviations that led to the event.

· Discuss the extent to which the incident was preventable.

· Research the impact of the same type of adverse event or near miss in other facilities.

2. Analyze the implications of the adverse event or near miss for all stakeholders.

· Evaluate both short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze how it was managed and who was involved.

· Analyze the responsibilities and actions of the interprofessional team. Explain what measures should have been taken and identify the responsible parties or roles.

· Describe any change to process or protocol implemented after the incident.

3. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.

· Analyze the quality improvement technologies that were put in place to increase patient safety and prevent a repeat of similar events.

· Determine whether the technologies are being utilized appropriately.

· Explore how other institutions integrated solutions to prevent these types of events.

4. Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.

· Identify the salient data that is associated with the adverse event or near miss that is generated from the facility’s dashboard. (By dashboard, we mean the data that is generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management.)

· Analyze what the relevant metrics show.

· Explain research or data related to the adverse event or near miss that is available outside of your institution. Compare internal data to external data.

5. Outline a quality improvement initiative to prevent a future adverse event or near miss.

· Explain how the process or protocol is now managed and monitored in your facility.

· Evaluate how other institutions addressed similar incidents or events.

· Analyze QI initiatives developed to prevent similar incidents, and explain why they are successful. Provide evidence of their success.

· Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.

6. Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.

7. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

Submission Requirements

. Length of submission: A minimum of five but no more than seven double-spaced, typed pages.

. Number of references: Cite a minimum of three sources (no older than seven years, unless seminal work) of scholarly or professional evidence that support your evaluation, recommendations, and plans.

. APA formatting: Resources and citations are formatted according to current APA style and formatting.

Discussion: Analysis on an Adverse Event

Discussion: Analysis on an Adverse Event

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication

Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.