Write a comprehensive analysis (5-7 pages) of an adverse event or near miss from your nursing experience. Integrate research and data on the event to propose a quality improvement (QI) initiative to your current organization.
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.
This assessment’s goal is to address a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities with a quality improvement initiative to prevent future incidents.
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
For this assessment, you will prepare a comprehensive analysis on an adverse event or near miss that you or a peer experienced during your professional nursing career. You will integrate research and data on the event and use this information as the basis for a quality improvement (QI) initiative proposal in your current organization.
The following points correspond to the grading criteria in the scoring guide. The subbullets under 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 relating to each grading criterion.
Example Assessment: You may use the Adverse Event or Near-Miss Analysis Exemplar [PDF] for an idea of what an assessment receiving a proficient or higher evaluation would look like.
1. Analyze the missed steps or protocol deviations related to an adverse event or near miss.
Passing Grade: Analyzes the missed steps or protocol deviations related to an adverse event or near miss. Identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty where further information could improve the analysis.
2. Analyze the implications of the adverse event or near miss for all stakeholders.
Passing Grade: Analyzes the implications of the adverse event or near miss for all stakeholders. Identifies assumptions on which the analysis is based.
3. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
Passing Grade: Evaluates quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Identifies criteria by which to evaluate the technologies.
4. Incorporate relevant metrics of the adverse event or near-miss incident to support need for improvement.
Passing Grade: Incorporates relevant metrics of the adverse event or near-miss incident to support need for improvement. Evaluates the quality of the data.
5. Outline an evidence-based quality improvement initiative to prevent an adverse event or near miss.
Passing Grade: Outlines an evidence-based quality improvement initiative to prevent an adverse event or near miss. Impartially considers conflicting data and other perspectives.
6. Communicate analysis and proposed initiative in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling.
Passing Grade: Communicates analysis and proposed initiative in a professional, effective, and error-free manner, writing clearly and logically.
7. Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.
Passing Grade: Integrates relevant sources to support arguments, formatting citations and references, using APA style without errors.
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