InstructionsFor 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.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 leading to the event.• Explain 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 the short- and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze each stakeholder’s contribution to the event.• Analyze the interprofessional team’s responsibilities and actions. Explain what measures each interprofessional team member should have taken to create a culture of safety.• 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 put in place to increase patient safety and prevent recurrence of the near miss or adverse event.• Determine the appropriateness of the technology application for a specific patient or situation.• Research scholarly, evidence-based literature to learn how institutions can integrate solutions to prevent similar events.4. Incorporate relevant metrics of the adverse event or near-miss incident to support need for improvement.• Identify the salient data associated with the adverse event or near miss that is generated from the facility’s dashboard. Note: Dashboard means data generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management.o Analyze what the relevant metrics show.o 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. Use resources such as the Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Institute for Healthcare Improvement (IHI), and the World Health Organization (WHO).Outline a quality improvement initiative to prevent the recurrence of an adverse event or near miss.o Explain, from an evidence-based viewpoint, how your facility now manages or should manage the process or protocol.o Evaluate how other institutions addressed similar incidents or events.o Analyze QI initiatives developed to prevent similar incidents. Explain why they are successful. Provide evidence of their success.o Propose solutions for your selected institution that can be implemented to prevent similar future adverse events or near-miss incidents.Communicate analysis and proposed initiative in a professional, effective manner, writing content clearly and logically, with correct use of grammar, punctuation, and spelling.Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.Additional Requirements• Submission length: 5 typed, double-spaced pages.• Font: Times New Roman, 12 points.• Number of references: Cite a minimum of 5 current scholarly and/or authoritative sources to support your evaluation, recommendations, and plans. Current literature is defined as no older than 5 years unless it is a seminal work.• APA formatting: Citations and references must adhere to APA style and formatting guidelines. Consult these resources for an APA refresher:• APA Style & Format.• APA Module.• American Psychological Association. (n.d.). APA style. Retrieved from https://www.apastyle.org/Resources: Adverse Events and Reporting• laffey, C. (2018). Near-miss medication errors provide a wake-up call. Nursing, 48(1), 53–55.• Luckett, T., Phillips, J., Johnson, M., Garcia, M., Bhattarai, P., Carrieri-Kohlman, V., . . . Davidson, P. M. (2017). Insights from Australians with respiratory disease living in the community with experience of self-managing through an emergency department ‘near miss’ for breathlessness: A strengths-based qualitative study. BMJ Open, 7(12), 1–11.• Nursing Masters (MSN) Research Guide.• You may wish to conduct additional independent research as you prepare for Assessment 1. This guide can help direct you to appropriate, credible, and valid resources. Likewise, the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you.• Rudolphi, D. M., Madiraca, J., & Wheller, E. C. (2018). Medical-surgical clinical student error and near miss reporting. Nursing Education Perspectives, Publish Ahead of Print.• Vila Health: Adverse Event.• In this activity, you will have the opportunity to accompany a quality assurance analyst on an investigation of an adverse event that occurred at St. Anthony Medical Center, the third largest hospital in Minneapolis, Minnesota. This activity may stimulate your thinking as you identify an adverse event from your nursing experience for analysis in Assessment 1.• Winning, A. M., Merandi, J. M., Dorcas, L., Stepney, L. M. C., Liao, N. N., Fortney, C. A., & Gerhardt, C. A. (2017). The emotional impact of errors or adverse events on healthcare providers in the NICU: The protective role of coworker support. Jan: Leading Global Nursing Research, 74(1), 172–180.• Witteveen, T., Bezstarosti, H., de Koning, I., Nelissen, E., Bloemenkamp, K. W., van Roosmalen, J., & van den Akker, T. (2017). Validating the WHO maternal near miss tool: Comparing high- and low-resource settings. BMC Pregnancy and Childbirth, 17.Resources: Reporting Systems• These resources provide comprehensive event-reporting systems data and performance assessment information:• Hospital Consumer Assessment of Healthcare Providers and Systems. (n.d.). CAHPS hospital survey. Retrieved from https://hcahpsonline.org/• The Joint Commission. (n.d.). National Patient Safety Goals. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx• U.S. Food & Drug Administration. (n.d.). FDA adverse event reporting system (FAERS). Retrieved from https://www.fda.gov/Drugs/InformationOnDrugs/ucm135151.htm
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