- NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis.
Adverse Event or Near-Miss Analysis
The health service has always been the most critical aspect of preventive medicine. With significant advances in technology, healthcare providers of all specialties use quality improvement projects intently, yet there remains a prevalence of medical mistakes, which pose another threat to patients’ safety and well-being (Smith et al., 2020). Among what can be an endless list of reasons for these medical mistakes, the inability of interprofessional communication stands out as a fundamental problem.
This opening enables a detailed study of one occurrence of an adverse event or close call in healthcare, It is a vivid example which relies on personal nursing experiences. This examination will closely look at a specific adverse event or not a far story resulted from nursing practice, delivering a thorough appraisal of its implication, root, and possible QI amendment. Key figures/indicators and evidence-based findings are included to support the design of a strategy to improve patient safety by optimising treatment course delivery.
Implications of the Adverse Event for Stakeholders
Studying how all industry members are involved in an adverse incident or a mishap requires a strong comprehension of how each party’s role affected the occurrence. Patients and families are the final recipients of healthcare services, and these changes have immediate and long-term impacts on their care. They might soon start suffering from increased levels of anxiety, lack of trust towards healthcare providers, and the fear of their future quality of life (Jones & Smith, 2021).
The foundation of this analysis includes the conviction that patients and their families prioritize providing sound and efficient care and the trust in the healthcare professionals who put the health and well-being of their patients at heart (Brown et al., 2019). In addition, long-term effects of such stress can involve ongoing problems such as fear of entering the healthcare system for diagnosis or treatment. Ass a result, it can impact the lives and perception of the entire healthcare system.
NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis
The multi-professional team, which is a part of a health care centre and consists of nurses, physicians, and other health care professionals, experiences similar feelings when an error or a near miss occurs. The possible short-term outcomes would be the team members who handled the situation experiencing guilt, stress, and inadequacy (Smith & Johnson, 2022). Such feelings, like frustrationon anger, sham,e and depressio, stem from the conviction that nurses are meant to provide top-quality care and may break down when some errors occur. The possible long-term consequences are low morale, exhaustion, or occupational consequences, which may detrimentally affect the harmony and effectiveness of the healthcare team.
Adverse Event with Root Cause Analysis
Causality is the bread and butter of verification of process deviations, errors, and near misses. In this, one has to conduct a deep analysis of all the steps, protocols, sequence,s or skips of protocols putatively related to an adverse reciprocal event. The focus of this analysis should be to meticulously dissect (root cause analysis) the sequence of events and the series of actions and circumstances. To start, it is imperative to pinpoint the initial sources or stimuli that preexisted before the event. In this case, it may be about the type of patients and their particulars, such as age, gender, and experiences (Jones & Smith, 2021). In addition to the presenting symptoms, other contributing characteristics may include staffing levels, equipment availability, and anything else the caregivers may find relevant.
Aligning to this, adding a specific one of the key elements of the diagram is event time, which is determinant of the sequence of events. It is imperative to remember that the healthcare provider had an active role in the scenari,o including responding to thepatient’ss story and any other occurrence (Brown et al., 2019). The fact that every event is carefully scrutinized can reveal shortcomings, mistakes, and even lapses of judgment in applying existing protocols and practices.
The evaluation can tackle flaws like communication breakdowns, inadequate training, limited personnel, equipment malfunctions, and issues within the health organization (Garcia et al., 2019). Besides that, assessing patient outcomes and comparing them to the standard of care for each deviation will help categorize the severity of the adverse event, which could also be a quality concern in patient safety issues.
Evaluation of Quality Improvement Technologies Related to the Event
Formulating strategies to reduce the risks of errors and improve patient safety involves assessing activities and processes that prevent adverse events and near misses. Here’ss how you might approach this section of the analysis Here’ss how you might approach this section of the analysis:
Quality Improvement Actions or Technologies:
Implementing barcode medication administration systems (BCMA) will help reduce errors, as the patient’s identity and the accuracy of the medication administered will be verified (Smith & Johnson, 2022). Electronic health record (EHR) systems with inbuilt communication features play the part of a speed-fOD protocol through which quick communication among healthcare team members takes place and misinformation and errors are reduced (Brown et al., 2019).
Deployingg continuous monitoring systems of vital signs and clinical status enables early detection of impending patient deterioration. Consequently, this intervention improves hospital care and reduces the prevalence of adverse events such as cardiac arrests and sepsis (Garcia et al.,2019). Giving CDSS the unique ID of EHR platforms facilitates the clinician’s access to evidence-based guidelines and warnings for medication dosing, diagnostic testing, and treatment options that reduce the risk of errors and adverse effects (Jones & Smith, 2021). Transforming the interprofessional training through team training and simulation exercises will improve patient safety in highly stressful environments; thus, the care providers will have increased teamwork, communication, and situational awareness.
Criteria for Evaluation:
Consider the efficiency of these actions and technologies to reduce unsafe conditions like near misses or adverse events that have happened before in similar healthcare settings (Adams & White, 2020). Analyze the ease of using the strategies and their successful integration into existing workflows and systems, ensuring no clinical practice is interfered with incorrectly. Think about whether the intervention can become responsive to the differing needs of patients in various environmental contexts through scale-up across departments and healthcare facilities. (Parker et al., 2022).
Evaluate the cost/benefit of undertaking all the interventions, paying due attention to start-up investments, later maintenance charges, and savings from interventions that prevent adverse occurrences (Roberts, 2023). Conceptualize the sustainability of the interventions for the lack of long-term maintenance, including necessary things such as personnel training, system upgrades, and ongoing system maintenance.
Quality Improvement Initiative to Prevent a Future Adverse Event
Causing a quality improvement initiative to prevent potential future adverse events or near misses shall demand thorough information concerning the root causes and the factors of participation, which will be identified through the analysis (Brown et al.,2019). A good initiative in this case should look at the underlying problems and acknowledge various conflicting indicators and perspectives to adopt a holistic approach. The operation will address the induced issues through the root cause analysis. It would comprise things like the fixation of the root cause of communication gaps, insufficient training, low worker numbers, and systemic problems in the healthcare organization (Garcia et al., 2019).
Realizing this interprofessional involvement is critical in increasing patient safety. Creating multidisciplinary teams or teams consisting of professionals from different health sectors facilitates the identification of the risks and vulnerabilities that might occur for collective response or action (Smith & Johnson, 2022). Devising and putting the standardized protocols and procedures for the risky areas, as these are identified based on analysis, is critical.
As such, protocols that are based on evidence and apparent so that all providers across the healthcare system can access them will lead to uniformity and observance of best practices (Jones & Smith, 2021). A continuous monitoring and evaluation system will be put in place to measure systematically the safety metrics of patient space and incidences of quality. Through sensing and analyzing adverse event reports, near-miss data, and patient feedback, we can trace trends, pinpoint patterns, and strive for improvement.
Conclusion
In a nutshell, the retrospective examination of the adverse event or near miss has revealed the policies, procedures, and trends that increase patient safety risks in healthcare. By reflecting on the event’s impact on all parties involved and conducting a retrospective team review, including an investigation into the chain of events, missed steps, and protocol breakdowns, we could detect areas for improvement and identify intervention points.
Analysis demonstrated the critical role of early preventive measures and explicit strategies to reduce adverse events and near misses. It underscored the importance of effective communication, standardization of protocols, continuous monitoring, and teamwork among professionals. Further, the analysis of effective quality improvement strategies or technology revealed other practical intervention strategies that can contribute to patient safety, such as the technique of medicine safety, communication tools, and patient monitoring systems.
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