Adverse Event or Near Miss analysis Essay.

Adverse Event or Near Miss analysis Essay.



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.


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.Adverse Event or Near Miss analysis Essay.

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.

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.Adverse Event or Near Miss analysis Essay.

The paper should address #1-7 below. Each section of the paper should address each number below. Example: section 1 of the paper should address #1 and bullet points below, Section 2 of the paper should address #2 and the bullet points below, etc..

  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.Adverse Event or Near Miss analysis Essay.
  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.Adverse Event or Near Miss analysis Essay.
  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.Adverse Event or Near Miss analysis Essay.

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.

Attached is the paper directions, scoring guide, and suggested but not required resources. Adverse Event or Near Miss analysis Essay.


The World Health Organization highlights that incidences of patient harm due to errors are the most common causes of morbidity and mortality across the globe. In well-developed nations, harm occurs in one of every ten patients in routine care (World Health Organization, 2015). The most harmful errors are human errors associated with; medical procedures, diagnosis, prescription and medication use, and 50% are preventable. In low and middle-income countries, up to 134 million incidences of adverse events happen annually because of unsafe care, leading to more than 2.6 million deaths (World Health Organization, 2015). Adverse Event or Near Miss analysis Essay.

Patient safety is a discipline in healthcare whose emergence is emphasized by the evolving complexity of healthcare systems and increasing incidences of patient harm in healthcare organizations (Najafpour et al., 2017). Patient safety purposes to reduce and prevent harm, risks, and errors to patients when receiving care since it is fundamental to the provision of quality healthcare services. The AHRQ (Agency for Healthcare Research and Quality) emphasizes that quality care should be patient-centric, effective, and safe, and to achieve the benefits of quality care, healthcare services must be efficient, timely, integrated, and equitable (Najafpour et al., 2017).Adverse Event or Near Miss analysis Essay.

This paper focuses on a patient safety issue involving a blood transfusion error that occurred in the author’s healthcare organization. The preventable event occurred in the identification and verification stages of blood transfusion. The analysis purposes to identify and reduce similar incidences that may occur in routine care.Adverse Event or Near Miss analysis Essay.

Analysis of Protocol Deviations Related to the Adverse Event

At the beginning of this year, as I worked in the ICU, a 28-year-old man presented with a gunshot injury on his left groin. The patient was severely hypotensive and hemorrhaging. His hemoglobin level was 7.0, confirming anemia and hypovolemia following the severe loss of blood. Based on the hospital’s massive blood transfusion protocol, this would necessitate several transfusions of packed cells (red blood cells). Thirty minutes later, another 26-year-old male patient whose first name was similar to that of the first patient was admitted after sustaining multiple injuries from a fatal road traffic accident. A chest x-ray revealed that he had internal bleeding, multiple fractured ribs, and extensive trauma to tissues at the right groin. This patient’s hemoglobin level was 7.5, which also warranted an immediate transfusion with packed red blood cells as part of the definitive intervention and resuscitation efforts to stabilize his hemodynamic status. Adverse Event or Near Miss analysis Essay.

Before beginning transfusion, the hospital’s blood transfusion protocol requires that two must complete an identification check for the blood product and the patient independently at the patient’s bedside. This independent identification check comprises of the following: the integrity of the container and blood product, patient’s blood group and rhesus factor, medical record number, confirmation of the donor’s and recipient compatibility as confirmed by the serologist’s signature, donor blood group and rhesus factor, donor identification number, patient’s full name, time and expiry date of blood product.Adverse Event or Near Miss analysis Essay.

However, due to the bus nature of the ED, the author did not perform a pre-transfusion independent double-check at the patient’s bedside as required. Instead, we did the check from the nursing station before proceeding to start the transfusion. Consequently, each patient was transfused with the wrong blood product. It was only by good luck that both patients had the same blood group and Rhesus factor, and were to receive the same blood product. This helped to avert the catastrophe of a hemolytic transfusion reaction.Adverse Event or Near Miss analysis Essay.

Implications for All Stakeholders

Nurses and all healthcare professionals get embarrassed by their mistakes and are likely to conceal or defend themselves by shifting blame. However, respecting the autonomy of patients is vital, as is the significance of veracity. Non-maleficence, fidelity, and beneficence are ethical principles that guide disclosure and reporting in nursing practice. Although it was by chance this incident did not result in any adverse events, nurses and other healthcare providers are obligated ethically and legally to report benefits and risks of procedures and treatments through informed consent mandates.Adverse Event or Near Miss analysis Essay. The same mandate commits them to report any errors that may occur. It is for this reason that the author accepted responsibility for the error that occurred, reported, and discussed it with colleagues and disclosed to patients with apologies. By telling the truth, the patients shared their trust with the author. Although the patient’s response was contrary to the author’s expectations, in the short term, it strengthened the nurse-patient therapeutic relationship.Adverse Event or Near Miss analysis Essay.

This incidence promoted patients’ trust in the organization, as it did not breach the principle of truthfulness as reflected in its mission. When healthcare organizations deceive patients, the relationship between providers-patients damages, and this can ultimately affect an organization’s reputation and financial performance. However, in the author’s case, admittance strengthened the provider-patient relationship. Besides, it influenced the organization to conduct periodic assessments to ensure prompt reporting of procedures, policies, and risk management strategies by identifying initiatives for quality and performance improvement.   Adverse Event or Near Miss analysis Essay.

Quality Improvement Technologies to Reduce Risks and Increase Patient Safety

In routine care especially in busy hospital environments, transfusion errors are likely to occur due to misidentification of a blood container, a patient, or a patient’s blood sample. To promote the safety of patients and prevent a re-occurrence of a similar event, the organization integrated the use of a prototype system consisting of a bar-code scanner and wristbands, portable printer for blood samples, and an automated blood bank analyzer for routine blood transfusions.Adverse Event or Near Miss analysis Essay.

As described by Najafpour et al. (2017), this technology requires nurses to use data from the organization’s health information system to print a bar-coded patient identification wristband. The wristband contains three major identifiers: the patient’s initial and last names, birth date, and medical record number. The same identifiers are used to label blood samples. The bar-code system is used to conduct verification checks in all processes of blood transfusion starting with the identification of patients and blood products (Najafpour et al., 2017). An electronic match in the identifiers prompts a nurse to begin a transfusion. If there is no match, the system sounds an alarm as a signal.Adverse Event or Near Miss analysis Essay.

Since nurses received adequate training regarding the use of the proposed bar-code technology, incidences of blood transfusion adverse events due to misidentification errors reduced from 10% to 4 % (6% decrease). Other organizations have similarly embraced the use of similar technology to reduce the risks of blood transfusion adverse events that result from human errors.Adverse Event or Near Miss analysis Essay.

Metrics To Support The Need For Improvement

Our healthcare organization collects different sets of data including data and events on blood transfusion. This initiative was influenced by previous incidences that resulted in preventable severe transfusion reactions and lawsuits against the hospital and healthcare staff. Nurses are strictly required to observe and report all transfusions using an incident report form. The incident report includes the following details: patient’s identification, the transfused blood component, type of incident (near miss, protocol deviation, incorrect blood component, bacterial or purpura), patient outcome (death, full recovery with prolonged stay, recovery with morbidity or full recovery without effects), severity rating and the type of transfusion reaction. The hospital’s laboratory department sends this report to the State blood transfusion office for recommendations on improvement.Adverse Event or Near Miss analysis Essay.

In this case, the most significant metrics for improvement are patient identification, shortcuts when conducting patient and identity checks and inadequate training of staff to understand the significant consequences of identification errors in blood transfusion. Nurses in other departments also conduct and monitor blood transfusions. They follow the same blood transfusion protocol before, during, and after transfusion.Adverse Event or Near Miss analysis Essay.

Quality Improvement Initiative To Prevent Future Adverse Events

Transfusion errors are among the most common adverse events that can result in patient harm. Clinical scenarios involving the transfusion of huge volumes of blood products in busy and chaotic environments such as EDs increase the risks of errors. Fortunately, in the author’s case, the transfusion error was with compatible patients thus, no harm was recorded. As highlighted by Najafpour et al. (2017), events of such nature permit the assessment of processes through strategies such as root-cause analysis. To prevent future incidences, nurses must receive appropriate ongoing training. The training should focus on patient safety and blood bank policies on the release, transport, and administration of blood products.Adverse Event or Near Miss analysis Essay.

Nurses working in busy environments such as the ED should embrace interprofessional collaboration and designate unique product verification and transfusion roles to laboratory personnel (Najafpour et al., 2017). ED nurses can guide and supervise resuscitation efforts and ensure that the right transfusion protocol is adhered to for all patients. Regarding environmental distraction, nurses can remove all the non-essential personnel in the ED after assigning tasks. This also helps to prevent congestion, which can hinder concertation. On the labeling of transfusion blood products, Patil & Shetmahajan (2014) suggest that the blood bank should implement a unique transfusion protocol number for every patient and attach it to the cooler. Besides, the labels on coolers should include a patient’s designated unit, room number, and identification number for the product to be transfused. Adverse Event or Near Miss analysis Essay.