Adverse Event Or Near Miss Analysis

  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.
  8. 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.
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