Adverse Event Analysis Assignment Paper

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 Adverse Event Analysis Assignment Paper.

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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.

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 Analysis Assignment Paper

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 Adverse Event Analysis Assignment Paper.

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:

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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.

RESOURCES FOR REFERENCES:
These resources provide comprehensive event-reporting systems data and performance assessment information:

Agency for Healthcare Research and Quality. (2021)Adverse Event Analysis Assignment Paper. WebM&M: Case studies. https://psnet.ahrq.gov/webmm
Centers for Medicare & Medicaid Services. (2020). Core measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-Measures
Institute for Healthcare Improvement. (n.d.). http://www.ihi.org/Pages/default.aspx
Hospital Consumer Assessment of Healthcare Providers and Systems. (n.d.). CAHPS hospital survey. https://hcahpsonline.org/
Joint Commission. (2021). National patient safety goals. https://www.jointcommission.org/standards/national-patient-safety-goals/
U.S. Food & Drug Administration. (n.d.). FDA adverse event reporting system (FAERS). https://www.fda.gov/Drugs/InformationOnDrugs/ucm135151.htm

These resources provide you with detailed examples of models to improve communication and create effective interventions. They also illustrate how quality and research can be integrated. You’ll see illustrations of the nature of shared decision making. This will be important to you as you analyze adverse events and near misses to understand their sources.

Beiler, J., Opper, K., & Weiss, M. (2019). Integrating research and quality improvement using TeamSTEPPS: A health team communication project to improve hospital discharge. Clinical Nurse Specialist, 33(1), 22–32
Cabigon, R. D., Wojciechowski, E., Rosen, L., Miller, D., Mix, C., & Chen, D. (2019). Interprofessional collaboration and peer mentors for bowel education in spinal cord injury: A case consultation. Rehabilitation Nursing, 44(2), 123–127.
Dunn, S. I., Cragg, B., Graham, I. D., Medves, J., & Gaboury, I. (2018). Roles, processes, and outcomes of interprofessional shared decision-making in a neonatal intensive care unit: A qualitative study. Journal of Interprofessional Care, 32(3), 284–294.
Li, J., Talari, P., Kelly, A., Latham, B., Dotson, S., Manning, K., Thornsberry, L., Swartz, C., & Williams, M. V. (2018). Interprofessional teamwork innovation model (ITIM) to promote communication and patient-centred, coordinated care. BMJ Quality & Safety, 27(9), 700–709.
Moradi, K., Najarkolai, A. R., & Keshmiri, F. (2016). Interprofessional teamwork education: Moving toward the patient-centered approach. The Journal of Continuing Education in Nursing, 47(10), 449–460.
Scaria, M. K. (2016). Role of care pathways in interprofessional teamwork. Nursing Standard, 30(52), 42.
NCQA. (n.d.). http://www.ncqa.org/ Adverse Event Analysis Assignment Paper

Introduction

Adverse events and near misses are unwelcome indicators of deficiencies in a provider’s patient safety initiative. Given that adverse events are often a result of actions or inactions on the part of the provider, government and regulatory agencies use patient safety as a yardstick for quality of care provided. Notably, bodies such as the Agency for Healthcare Research and Quality (AHRQ) maintains a database on organization’s performance in the safety arena using patient safety indicators (PSIs) such as pressure ulcer rate and birth trauma rate, among others. The value-based reimbursement system used by Medicare similarly uses quality of care as basis for payments to providers. This discussion looks into adverse events or near misses, their impacts and implications, and their control through quality improvement approaches.

Case Study for Near-miss in My Facility

I recall a near-miss discharge against medical advice event that a colleague experienced in my workplace. The case was a 67-year-old female patient placed on bed rest after postoperative complications. The event occurred during the night shift and the unit was understaffed. The patient’s external catheter system got detached and the patient repeatedly rang the call button requesting assistance, with no success. The patient resorted to hoping down the hallway on one leg to find a nurse, an effort that was also unsuccessful. When the nurse eventually presented to change the urine-soaked bedding, they found an angry agitated patient. Rather than apologize, the floor nurse was defensive and used condescending language. Another nurse complained to the patient’s family that they were being difficult Adverse Event Analysis Assignment Paper.

The patient ultimately decided to leave against medical advice on account of unfair treatment (Hessels et al, 2019). The floor nurse had the patient escorted out of the hospital with no physician on duty providing discharge instructions, education, or medication for the patient’s urinary incontinence and deep vein thrombosis. The charge nurse was unaware what had occurred until the next day. Fortunately, the family member was able to assist the patient into the house and into bed. Medications were later picked up at a local pharmacy and it took a nurse home visit and numerous phone calls to teach the patient how to take the medications.

Adverse Event at Other Facility

Even though the case with my colleague did not result in a catastrophic outcome, the setting was rich with likelihood for an adverse event. A discharge against medical advice (DAMA) in another hospital in my network resulted in loss of life and legal action. That case involved an alcoholic 55-year-old man with early dimentia admitted with abdominal pain the physician attributed to a volvulus. The consulting physician recommended a hemicolectomy but it could not be carried out until the next day. It was recommended the patient stayed overnight in the hospital. Due to alcoholism, a formal mental status test had revealed that the patient lacked medical decision-making capacity. At about 0100hours at night, the patient said he wanted to leave to take care of his pets. The charge nurse and floor nurse were unaware of the patient’s mental health status. They informed the nightfloat resident of the patient’s wish to leave. The resident took a glance at the chart, asked a few questions to the patient, and permitted him to leave against medical advice. The patient was found one block away a few hours later, unconscious on the sidewalk. Attempts to resuscitate him failed Adverse Event Analysis Assignment Paper.

Implications of Adverse Event From DAMA

Some adverse effects of discharge against medical advice are clearly evident in the two cases above. In the first case, the patient was exposed to fall risk and poor health from lacking nursing attention both in the hospital and later at home (Hessels et al, 2019). It is only by fortune that the patient did not come to harm. In the second case, loss of life resulted in the hospital paying for harm caused and the resident facing disciplinary action. In both cases, patients were unduly exposed to risk of adverse events and the DAMA was a direct consequence of the actions of healthcare workers. In the first case, the patient’s family had the burden of providing care and in the second case, loss of a loved one. The hospital experienced no lawsuit or financial loss in the first case, while in the second, patient’s death led to legal action, financial and reputational loss for the facility.

The impact of discharges against medical advice (DAMA) on the larger healthcare sector is significant. For one, DAMA patients have higher 30-day and 15-day readmission rates.  Onukwugha & Alfandre (2019) found in a study of general patients that patients leaving against medical advice have a 15-day readmission rate of 21% against a rate of 3% for the control group. This disparity was found to hold for the 30-day and 75-day readmission rates. Patient readmissions contribute to increased cost of healthcare provision. Kwok et al (2019) found that patients discharged against medical advice were at 40% higher risk of death for myocardial infarction or unstable angina for two years following discharge. Even though specific causative factors for DAMA are difficult to pinpoint, studies have correlated male sex, no medical insurance or only Medicaid, substance abuse, younger age, and low socioeconomic status to increased risk of leaving against medical advice. This serves to widen disparity in access to healthcare between insured and uninsured persons, and for people of low versus high income Adverse Event Analysis Assignment Paper.

Factors behind observed adverse events

Discharges against medical advice are fertile ground for adverse events, or at best, near misses, as evident from the case studies. In each of the cases, breakdown in professional communication resulted in the discharge. In the incident at my workplace, staffing shortage was the primary factor in the chain of consequence leading to the discharge. The floor nurse was overworked, tending to too many patients and the discharged patient’s call alarm was likely but one of many that needed attending to. The American Association of Critical-Care Nurses affirms that alarm fatigue can result in desensitization to call alerts and a higher incidence of missed alarms (Lewis & Oster, 2019). Also, staffing shortages lower the productivity of available staff. The nurse also failed to acknowledge that non-response to call alarms caused distress in the patient. Unprofessional conduct on their part further aggravated the situation.

In the second case, lack of information exchange between the treating physician and the nursing team, and the resident’s disregard for indicators of poor judging ability caused the DAMA (Tan et al, 2020)Adverse Event Analysis Assignment Paper. If the nurse was aware that the mental status exam indicated the patient had impaired decision-making ability, they could have encouraged the patient to stay. Moreover, the resident may have held the patient if they had critically analyzed the chart rather than glance over it.

Quality Improvement Initiatives

Some quality initiatives that can be implemented to improve patient safety include proper staffing, training on communication strategies, use of standardized protocols and countersigns for discharges, follow-up arrangements, and careful documentation. Optimal nurse-to-patient ratio is important in facilitating prompt care provision and in reducing fatigue and burnout in staff (Lewis & Oster, 2019). Effective communication where the nurse acknowledges patient’s distress and expresses accountability for the patient’s situation can ameliorate frustration and improve patient satisfaction (Rodziewicz et al, 2022). In addition, flexible negotiation can help de-escalate a situation that could result in a patient leaving against medical advice. Follow-up arrangements are crucial in maintaining an open line of communication for use in patient education and medication administration. Careful documentation in the EHR is crucial in preventing miscommunications and possible legal action (Rodziewicz et al, 2022)Adverse Event Analysis Assignment Paper.

Conclusion

Adverse events and near misses result from clinical practice oversights. Discharges against medical advice are reflective of patients’ satisfaction with a provider’s services. DAMA lead to adverse events or near misses and cause higher readmission and mortality rates, and higher overall costs of healthcare provision. Discharge against medical advice is a tentative balancing act between respecting patient autonomy and healthcare practitioners’ duty to provide care. While patient independence holds precedence, nurses can mitigate the risk of adverse events by making follow through arrangements, following the discharge protocol, and verifying patients’ decision-making capacity. With respect to my workplace, proper staffing and training on communication and de-escalation strategies are initiatives that can the implemented to minimize the incidence of adverse events and near misses.

References

Hessels, A., Paliwal, M., Weaver, S. H., Siddiqui, D., & Wurmser, T. A. (2019). Impact of

patient safety culture on missed nursing care and adverse patient events. Journal of nursing care quality, 34(4), 287.

Kwok, C. S., Walsh, M. N., Volgman, A., Alasnag, M., Martin, G. P., Barker, D., … &

Mamas, M. A. (2019). Discharge against medical advice after hospitalisation for acute myocardial infarction. Heart, 105(4), 315-321.

Lewis, C. L., & Oster, C. A. (2019). Research outcomes of implementing cease: an

innovative, nurse-driven, evidence-based, patient-customized monitoring bundle to decrease alarm fatigue in the intensive care unit/step-down unit. Dimensions of Critical Care Nursing, 38(3), 160-173.

Onukwugha, E., & Alfandre, D. (2019). Against medical advice discharges are increasing for

targeted conditions of the medicare hospital readmissions reduction program. Journal of General Internal Medicine, 34(4), 515-517.

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical error reduction and

prevention. In StatPearls [Internet]. StatPearls Publishing.

Tan, S. Y., Feng, J. Y., Joyce, C., Fisher, J., & Mostaghimi, A. (2020). Association of

hospital discharge against medical advice with readmission and in-hospital mortality. JAMA network open, 3(6), e206009-e206009. Adverse Event Analysis Assignment Paper

Guiding Questions

Adverse Event or Near Miss Analysis

This document is designed to give you questions to consider and additional guidance to help you successfully complete the Adverse Event or Near Miss Analysis assessment. You may find it useful to use this document as a prewriting exercise, an outlining tool, or a final check to ensure you have sufficiently addressed all the grading criteria for this assessment. This document is a resource to help you complete the assessment. Do not turn in this document as your assessment submission.

For examples of adverse events or near misses, visit:

Agency for Healthcare Research and Quality. (2021). WebM&M cases & commentaries. https://psnet.ahrq.gov/webmm

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

• What are the possible short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community, et cetera)?
• What are the responsibilities and actions of the interprofessional team related to the adverse event or near miss?
• What measures should have been taken? Who are the responsible parties or roles?
• How did the incident impact the stakeholders? Did it change how they do their work, or how or what they report? Adverse Event Analysis Assignment Paper

Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.

• How did the event result from a patient’s medical management rather than from the underlying condition?
• What were the missed steps or protocol deviations that led to the adverse event or near miss? What was overlooked? Why?
• What kind of interprofessional communications could have prevented this event?
• To what extent was the adverse event or near miss preventable? Adverse Event Analysis Assignment Paper

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

• What quality improvement technologies are in place to increase patient safety and reduce risks that pertain to this adverse event? What would prevent it from happening in the future?
• Are those technologies being utilized appropriately? How could they be more usefully employed?
• How do other institutions prevent these types of events from occurring?
• What data are generated from the facility’s dashboard related to the selected incident? (By dashboard, we mean the data that are generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management. This is not something you will find online or in the Capella library.)
• What data are associated with the adverse event or near miss? What do the relevant metrics show? (Patient satisfaction and readmission rates are important metrics. Look at trending data and compare to see where relevant metrics are headed.)
• What research or data related to the adverse event or near miss is available outside of your institution?
• Compare internal data to external data. What do you find? Adverse Event Analysis Assignment Paper

Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.

• How was the incident managed and monitored in the selected institution?
• What quality improvement initiatives have been shown to work? Why are they successful? What is the evidence?
• What elements can be applied to prevent future adverse events or near misses?
  

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Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

• Is your analysis logically structured?
• Is your analysis 5–7 double-spaced pages (not including title page and reference list)?
• Is your writing clear and free from errors?
• Does your analysis include both a title page and reference list?
• Did you use a minimum of three sources? Were they published within the last five years?
• Are they cited in current APA format throughout the plan? Adverse Event Analysis Assignment Paper