Adverse Event or Near-Miss Analysis - 5 pages

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.

A comprehensive analysis on an adverse event or near miss that someone experienced during professional nursing career.

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.
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.
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.
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.
- 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. 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.
- Explain, from an evidence-based viewpoint, how your facility now manages or should manage the process or protocol.
- Evaluate how other institutions addressed similar incidents or events.
- Analyze QI initiatives developed to prevent similar incidents. Explain why they are successful. Provide evidence of their success.
- Propose solutions for your selected institution that can be implemented to prevent similar future adverse events or near-miss incidents.

Running head: ADVERSE EVENT OR NEAR-MISS ANALYSIS 1

Adverse Event or Near-Miss Analysis

Learner’s Name

Capella University

Quality Improvement for Interprofessional Care

Month, Year

Comment [JS1]: This submission is
very well crafted according to the

rubric. It is written in a scholarly
voice and free of APA and

grammatical errors.

ADVERSE EVENT OR NEAR-MISS ANALYSIS 2

Adverse Event or Near-Miss Analysis

Preventable adverse events are among the top causes of death in the United States.

Estimates reveal that 210,000 to 400,000 fatal adverse events occur every year (Allen, 2013).

Examples of preventable adverse events are hospital-acquired diseases, medication errors, and

patient falls. The focus of this adverse-event analysis is medication errors, also known as adverse

drug events (ADEs), such as medication overdoses or administration of wrong medicines. The

analysis will recommend strategies to mitigate ADEs based on a case of medication overdose

observed in the emergency department (ED) at TrueWill General Hospital (TGH), a

multispecialty hospital in the United States.

A 40-year-old woman was brought to the ED after suffering a seizure. Before she was

discharged, she suffered a second seizure and the ED doctor prescribed 800 mg of phenytoin, an

anti-seizure medication, to be given intravenously (IV). The ED nurse misread the prescribed

dosage in the electronic medical record (EMR) and administered 8000 mg, which was 10 times

greater than the prescribed dosage. The patient died soon after the lethal infusion (Manias, 2012).

The incident shows that the nurse made a series of cognitive errors in medication

management and missed key steps (Manias, 2012), which will be explained in the analysis

report. Additionally, the analysis will examine the implications of adverse events on multiple

stakeholders. Relevant evidence and metrics will be incorporated when making suggestions for

improvement of patient safety at TrueWill General Hospital.

Analysis of Missed Steps Related to the Adverse Event

Emergency departments are susceptible to adverse events because of the unscheduled

nature of patient presentation, urgency, and severity of cases. In such high-pressure situations,

ADVERSE EVENT OR NEAR-MISS ANALYSIS 3

clinicians must be more careful when treating a patient (Manias, 2012). Retracing the steps taken

by the nurse revealed several missed steps in the delivery of care.

To begin with, the drug dispensing machines in the ED were stocked with phenytoin in

250 mg vials; the correct dose required only 3.2 vials. As the nurse had misread the dose, she

needed 32 vials of the drug. She took the vials from three different drug dispensers and

administered the dose using two IV bags as well as a piggyback line (Manias, 2012). The nurse

did not question the difficulty in procuring and administering the drugs, nor did she ask anyone

to validate her calculations. Furthermore, she was not asked why she was removing so many

vials from the drug dispensers in the ED unit.

The scenario also shows that the nurse was unaware of the toxic nature of phenytoin

when administered in large quantities; she was unable to recognize the warning signs.

Additionally, the fact that the nurse could remove 32 vials is evidence of the technical drawbacks

of the automated drug-dispensing machines. The machines were not programmed to send out

alerts when large quantities of medications, especially high-alert medications like phenytoin,

were dispensed (Manias, 2012). They were also not synced to the patient’s medical record.

Therefore, the machines contained no information on drug preparation or correct dosages and did

not display any warning signs.

Various systems factors such as communication, leadership, education, training, and

innovation of health care technology influenced the ED nurse’s clinical performance. The factors

originate from the adaptation of systems theory into health care (Huber, 2017). There are,

however, areas of uncertainty regarding the factors becoming problematic in TGH’s scenario.

For example, the nurse’s hesitation to consult her team could have been caused by staff

management problems such as conflict, overwork, or shortage of ED staff. Similarly, her lack of

awareness of

ADVERSE EVENT OR NEAR-MISS ANALYSIS 4

dosages and safety measures indicates gaps in education and training. Such problems are a result

of a breakdown of systems factors. Further evaluation is essential to understand the root causes

of adverse events and systems problems. Ignoring root causes can result in similar adverse

events in the future and negatively impact the stakeholders.

Implications of the Adverse Event on Stakeholders

Since medicine is a profession that depends on interpersonal relationships, adverse events

have emotional, psychological, and professional consequences on all stakeholders. Patients and

their families are the first victims of adverse events, while health care professionals and the

organization become the second and third victims, respectively (Mira et al., 2015). A similar

inference can be made about the adverse event at TGH; the inference is supported by certain

assumptions about the health care environment. General assumptions about health care are as

follows: (a) quality health care is a result of positive relationships among all stakeholders

(Huber, 2017); (b) stakeholders are part of a high-risk environment where errors in clinical

practice are common; (c) health care professionals are not always responsible for errors, as errors

are often caused by a breakdown in systems factors (Manias, 2012); and (d) errors diminish the

morale and job satisfaction of health care professionals and lead to more adverse events (Huber,

2017).

The analysis of implications for stakeholders begins with identifying how each category

of victims is impacted. The first victims expect hospital stays and procedures to be safe and

beneficial. When a patient suffers an injury or dies because of medical negligence, the family

may feel aggrieved and may require counseling and support. They may feel unnerved and scared

by health care professionals (Bernhard, 2013) and hesitate to seek medical treatment in the

future. The study reported that health care professionals were traumatized after committing a

5 ADVERSE EVENT OR NEAR-MISS ANALYSIS

preventable error or witnessing an adverse event. They may lose confidence, abandon their

careers (Bernhard, 2013), and experience anxiety or depression (Mira et al., 2015). Adverse

events are damaging to careers, and nursing professionals may face difficulty in finding another

job (Bernhard, 2013).

Adverse events also affect the organization—the third victim—by damaging its

reputation. Adverse events can discourage people from seeking treatment at a particular hospital

(Mira et al., 2015). Moreover, as most preventable errors are not covered by Medicaid and

Medicare services, the hospital may lose a significant amount of reimbursement money.

It is important that health care organizations such as TGH find ways to minimize the

impact of adverse events on stakeholders. The current trend in quality improvement

(QI) is focused on reducing human errors through automation of health care technologies. In the

case of TGH, the existing level of automation of patient records and drug dispensers is

insufficient and must be replaced. The next section recommends and discusses the benefits of a

popular QI technology—patient care dashboards.

Evaluation of Quality Improvement Technologies

Performance measurement and reporting by health care professionals are the crux of QI

because transmitting, organizing, analyzing, and displaying performance data help in identifying

areas that need improvement (Ghazisaeidi, 2015). A recent development in QI technologies is the

introduction of visual dashboards. Dashboards are interactive performance management tools

that use graphic and easy-to-use formats to present specific metrics or key performance

indicators (KPIs) on a single computer screen (Ghazisaeidi, 2015). Implementing a dashboard

can help TGH improve quality of care and patient safety.

ADVERSE EVENT OR NEAR-MISS ANALYSIS 6

Studies show that the use of data-driven dashboards improves patient safety and

accelerates cost-reduction efforts. A dashboard reduces human errors in processes and minimizes

the cognitive effort needed to make decisions, thereby saving time and increasing efficiency and

accuracy. The KPIs aggregate data collected from various sources. For example, clinical data

incorporated into a dashboard include patient information gathered from physician or nurse

charts. A dashboard can also consolidate metrics about market dynamics, innovation for long-

term sustainability, and availability of financial and human resources for managers to analyze

(Weiner, Balijepally, & Tanniru, 2015).

To help TGH efficiently customize the dashboard to its specific clinical context, the tool

should be tested and evaluated using certain criteria. The categories for each criterion are as

follows: (a) easy customization; (b) knowledge discovery; (c) security; (d) information delivery;

(e) visual design; (f) alerts; and (g) system connectivity and integration (Karami, 2014). These

criteria can be used for all types of dashboards and health care settings.

While the design features are important, the dashboard is only useful if the KPIs provide

valuable data. Hence, the selection and development of KPIs are critical steps in QI at TGH

without which the organization risks ignoring areas that require corrective action

(Ghazisaeidi, 2015).

Relevant Metrics of Quality Improvement for TrueWill General Hospital

The KPIs are the most valuable content in a dashboard. They measure performance

across the organization using a combination of administrative and clinical data sets. To prevent

overloading the electronic dashboard, only a limited number of KPIs concerning high-priority

areas is selected. These KPIs are based on evidence-based academic literature. Data for each KPI

is sourced from different source systems in the organization such as the accounting system,

7 ADVERSE EVENT OR NEAR-MISS ANALYSIS

human resources system, and clinical system (Ghazisaeidi, 2015). For example, clinical data are

sourced from reports on whether clinicians treated the correct patient, addressed the equipment

or supplies needed, prescribed the correct medication or anesthesia at the appropriate time, and

detected patient allergies (Hagland, 2012). For the adverse event analysis report, the relevant

KPIs will focus on clinical and patient-centric metrics.

Health care agencies such as the Agency for Healthcare Research and Quality (AHRQ)

have developed their own metrics that address various aspects of quality: patient safety,

prevention quality, inpatient quality, and pediatric quality. TGH can customize its clinical and

patient-centric KPIs for the dashboard from these aspects. Examples of relevant AHRQ metrics

that are applicable to the ED adverse event include (a) death rate in low-mortality-diagnosis-

related groups; (b) accidental puncture or laceration rate; (c) heart failure mortality rate; and (d)

dehydration admission rate (AHRQ, 2015a, 2015b, 2015c).

The ED department at THG can include other relevant KPIs in the dashboard such as (a)

monthly averages for patient length of stay (inpatient and outpatient); (b) patients in the ED who

left without being seen (monthly); (c) radiology test (CT scan and x-ray), start to final dictation

turnaround time (Weiner, Balijepally, & Tanniru, 2015); (d) speed of onset of pain relief; (e)

cost-reduction percentage per patient; and (f) risk of drug interactions (Dolan, Veazie, & Russ,

2013).

The evidence base for the selected KPIs consists of peer-reviewed studies. Hagland

(2012) proved the success of the dashboard for patient safety optimization at the Saint Luke’s

Mid America Heart Institute, Missouri. The dashboard increased communication within medical

teams, reduced safety errors, and improved coordination between the teams. Dolan, Veazie, and

Russ (2013) studied the effectiveness of the electronic dashboard as a decision-making tool. The

results showed that the dashboard had potential to foster informed decision making and patient-

ADVERSE EVENT OR NEAR-MISS ANALYSIS 8

centered care. Weiner, Balijepally, and Tanniru (2015) studied the integration of data-driven

dashboards at the St. Joseph Mercy Oakland Hospital in Michigan. The study reported tangible

benefits such as KPIs reporting reduced adverse event rates and intangible benefits such as

increased accountability across the organization, self-improvement among nurses, and improved

unit performance.

The dashboard is just the technological component of quality improvement. TGH

requires a broader QI framework that incorporates organizational strategies to overcome

problems in the ED that resulted in the death of the patient. A suitable framework will be selected

after evaluating different perspectives and data about quality improvement.

Outline for a Quality Improvement Initiative for TrueWill General Hospital

The health care industry has adopted many QI and measurement models over the years.

Two popular models in quality improvement are the Six Sigma and LEAN models. Both models

have similar goals: eliminate operational waste and defects to improve quality and efficiency of a

system. The main difference between Six Sigma and LEAN is in the approaches to identifying

causes of defects and errors. According to Six Sigma, variations in processes cause errors, while

LEAN thinking highlights unnecessary steps as the cause of operational waste and errors

(AHRQ, 2017).

As both process variations and unnecessary steps can cause errors, the combination of the

LEAN and Six Sigma models can be implemented at TGH as its quality improvement outline.

The hospital can follow the LEAN Six Sigma model’s DMAIC approach. DMAIC is a five-step

approach to process improvement: (a) define—identify key business issues; (b) measure—

understand current levels of performance; (c) analyze—identify root causes of process errors; (d)

improve—introduce strategies and tools to improve quality of process; and (e) control—maintain

9 ADVERSE EVENT OR NEAR-MISS ANALYSIS

new levels of performance across the organization (Huber, 2017). Implementing the LEAN Six

Sigma into all units and departments—not just the ED—at TGH will help streamline processes

proactively. By improving the whole system, the hospital can prevent communication gaps or

errors, disorganization, and breakdown of faulty systems. DMAIC steps will allow TGH to

enhance QI process using tools and strategies such as the dashboard.

The Institute of Health Improvement’s Plan-Do-Study-Act (PDSA) model and the

Baldrige criteria were other quality improvement perspectives that were considered (Huber,

2017). However, the PDSA insufficiently addressed specific types of errors caused by variations

or unnecessary steps, unlike the LEAN Six Sigma model. The Baldrige criteria too were

insufficient because their usage was more suitable for enabling educational excellence.

Additionally, there is extensive evidence supporting the LEAN and Six Sigma models in quality

improvement.

While the LEAN Six Sigma model and dashboards have a high success rate,

implementing the QI initiative depends on coordinated and collaborative efforts by multiple

stakeholders. Teamwork enables TGH’s health care professionals to optimize systems factors

and the quality of processes and prevent future adverse events.

Conclusion

The process of QI and ensuring patient safety is challenging because health care

organizations must simultaneously provide the highest quality of services and introduce cost-

reduction strategies. Quality improvement initiatives such as implementing dashboards must

focus on finding and fixing the root causes of errors or process inefficiencies. To identify the

root causes of errors, the organization should train health care professionals, update health care

technologies, and open lines of communication to meet the expectations of patients for safe,

timely, affordable, and quality care.

ADVERSE EVENT OR NEAR-MISS ANALYSIS

References

Agency for Healthcare Research and Quality. (2015a). Prevention quality indicators. Retrieved

from https://qualityindicators.ahrq.gov/Downloads/Modules/PQI/V50/PQI_Brochure.pdf

Agency for Healthcare Research and Quality. (2015b). Patient safety indicators. Retrieved from

https://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50/PSI_Brochure.pdf

Agency for Healthcare Research and Quality. (2015c). Inpatient quality indicators. Retrieved

from https://qualityindicators.ahrq.gov/Downloads/Modules/IQI/V50/IQI_Brochure.pdf

Agency for Healthcare Research and Quality. (2017). Section 4: Ways to approach the quality

improvement process. In The CAHPS ambulatory care improvement guide: Practical

strategies for improving patient experience. Retrieved from

https://ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-

process/sect4part2.html#4c

Allen, M. (2013, September 19). How many die from medical mistakes in U.S. hospitals?

[Ongoing investigative report]. ProPublica. Retrieved from

https://propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals

Bernhard, B. (2013, May 5). Medical errors leave devastating impact on families, professionals.

St. Louis Post-Dispatch. Retrieved from http://stltoday.com/lifestyles/health-med-

fit/health/medical-errors-leave-devastating-impact-on-families-

professionals/article_0cb6f031-fbc6-5b8f-bed9-610163dbf2f8.html

Dolan, J. G., Veazie, P. J., & Russ, A. J. (2013). Development and initial evaluation of a

treatment decision dashboard. BMC Medical Informatics and Decision Making, 13(1), 51.

Retrieved from https://search-proquest-com.library.capella.edu/docview/1347649264?pq-

origsite=summon

ADVERSE EVENT OR NEAR-MISS ANALYSIS 11

Hagland, M. (2012). A dashboard for OR patient safety optimization. Healthcare

Informatics, 29(8), 29–31. Retrieved from https://search-proquest-

com.library.capella.edu/docview/1038458450?pq-

origsite=summon&http://library.capella.edu/login%3furl=accountid=27965

Huber, D. L. (2017). Leadership and nursing care management (6th ed.) Philadelphia: W.B.

Saunders. http://dx.doi.org/10.7748/nm.21.6.13.s14

Ghazisaeidi, M., Safdari, R., Torabi, M., Mirzaee, M., Farzi, J., & Goodini, A. (2015).

Development of performance dashboards in healthcare sector: Key practical issues. Acta

Informatica Medica, 23(5), 317–321. Retrieved from https://search-proquest-

com.library.capella.edu/docview/1727377974?pq-origsite=summon

Karami, M. (2014). A design protocol to develop radiology dashboards. Acta Informatica

Medica, 22(5), 341–346. http://dx.doi.org/10.5455/aim.2014.22.341-346

Manias, E. (2012). Looking for meds in all the wrong places [Case study commentary].

Retrieved from https://psnet.ahrq.gov/webmm/case/282/looking-for-meds-in-all-the-

wrong-places?q=Looking+for+meds+in+all+the+wrong+place

Mira, J. J., Lorenzo, S., Carrillo, I., Ferrús, L., Pérez-Pérez, P., Iglesias, F.,… Astier, P. (2015).

Interventions in health organisations to reduce the impact of adverse events in second and

third victims. BMC Health Services Research, 15(1), 341–350. Retrieved from

https://search-proquest-com.library.capella.edu/docview/1780186926?pq-

origsite=summon&http://library.capella.edu/login%3furl=accountid=27965

Weiner, J., Balijepally, V., & Tanniru, M. (2015). Integrating strategic and operational decision

making using data-driven dashboards: The case of St. Joseph Mercy Oakland

Hospital. Journal of Healthcare Management, 60(5), 319–331. Retrieved from

Comment [JS2]: I would suggest
locating a more current reference.

This reference is on the cusp of being

outdated according to health care

research standards of being less than

five years. With this topic, I am sure
there are more updated references that

could be used instead.

Comment [JS3]: This is another
reference that should be updated for

the above reasons.

ADVERSE EVENT OR NEAR-MISS ANALYSIS 12

https://search-proquest-

com.library.capella.edu/docview/1733617419?OpenUrlRefId=info:xri/sid:summon&acco

untid=27965

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Adverse Events

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Stephanie Johnson

Capella University February 13, 2022

Introduction

According to Centers for Disease Control and Prevention one among four adults who are older fall annually, one among the five falls re-
sults into major injury. This paper is an adverse event of a comprehensive review during the professional writing career of the writer. The sce-
nario gets to be analyzed professionally; evidence-based data becomes applicable to support a proposal for quality improvement with an ob-
jective of decreasing the inpatient falls. Within this analysis, the hospital where this AE takes place will be identified as SRMC. Analysis of

an Adverse Event

Ms Linda happens to be a skilled nursing facility patient who is 70 years old. She was found wandering at the same time confused. The patient
got transported to the facilities emergency room to have her abrupt change of condition assessed. Her medical recent history noted a
complete surgery at the right hip in under two weeks before and got rehabilitation therapy. Ms Linda was diagnosed with kidney injury as well
as severe sepsis all linked to an infection within the urinary tract. A certified medical assistant had her shifted from the emergency room into
the general medical unit. After her arrival, CAN, took the room assignment from the nurse in charge before helping Ms Linda onto the bed.
When CAN went back to the emergency room, a code blue got initiated in another’s patient’s room. Nurse in charge of Ms Linda was helping in
the event. She got tangled in the bedding claiming her leg was hurt. After X-rays and examining the right hip, the results showed a fractured
hip requiring surgical interventions. The Ms Linda fall was because of medical management and not sepsis, the underlying condition. As
per the hospital protocols, the nurse upon arrival should complete a call evaluation at the general medical unit. The patient was all alone
in her room without supervision, while the nurse was not aware of Ms Linda’s arrival. Deviations from the known admission protocol for new
patients caused the AE. In the assessment stage, the missed steps are: · The nurse never got a call from the emergency room charge nurse be-
fore discharging Ms Linda from the ER. · The patient had no one attending to her · Fall assessment never got completed · The patient could not
reach the call light. Ensuring the established protocol regarding new patients’ admission is implemented would have had the adverse event
prevented. Nurse lacked the details regarding the patient’s arrival, and the occurrence of the medical emergency delayed the admission as-
sessment. If the Fall risk assessment was completed, it would have noticed Ms Linda to be a Fall risk. The same way, adverse effects like
falls happen within various health-care settings like residential homes and nursing facilities. Report from Healthcare Research and Quality
Agency states that 1.6 million residents of nursing homes, around 50% fall yearly. In addition, CDC have noted that out of four adults of 65 and
above living at home, fall annually. Very small percentage reports to primary care giver. The fall impact cost an estimate of $50.0 billion yearly
in healthcare. The long-term effects of the injuries, like being dependent, disability, absentia in work plus household tasks, minimizes the quali-
ty of life. Information might have enhanced the analysis. Questions are left unanswered whether the transporting CAN should have waited in
the room till completion of the medical emergency. Fall education knowledge gaps might exist in between organizational departments.
Additionally, the staffing uncertainty in the night shift might have led to the lack of management on preventing the Adverse event (Lee, et.al,

2018). Implications of Falls for All Stakeholders

Every stakeholder experiences long and short-term ramifications die to inpatient falls. Patients suffer instant implications, like psychological
and physical trauma plus pain. On top of a lengthy hospital stay, long term effects comprise of, community and personal loss of faith with-
in delivery of health care. The discovery is that the AE involved interdisciplinary team suffers from depression, anxiety plus a life quality that is
decreased. The health care experts might as well suffer social isolation, diminished professional confidence in addition to legal considerations.
Hospital institution faces repercussions as well due to inpatient falls. The Medicaid and Medicare Services centers has inpatient falls in-
cluded as a hospital-acquired condition that is non-reimbursable. The same way, additional extended hospital stays and extra resources to of-
fer services for inpatient falls get included within the cumulative revenue loss. The hospitals might as well face a decrease in the staff morale
resulting to loss of employees. Falls reflect system failures within organizational processes and structures. Evaluating the contribution of
every stakeholder to the AE might enhance the safety culture of the hospital. Patients tend to have gaps within perceived fall risks plus
falls commonality.

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Ms Linda has a changed perception because of confusion, a sepsis symptom plus being alone within a new area. The patient has an impaired
ability to know the intense of leaving her bed without any help. Emergency room nurse gave report to her receiving unit colleague (Murphy,
et.al, 2021). The fateful evening, newly hired CAN in the ER was in charge from a different department and was not aware of the ERs protocols
regarding transport and patient attendance. The staffing supervisor measures might have had the AE prevented. The charge nurse in the
ER should have oriented the CAN regarding the protocols of the department, especially in an emergency. Instant changes were some to the ER
transfer protocols, staffing policy plus CAN orientation after the event. The staffing supervisors should confirm with CANs ability to operate on
different units from the Unit director. CAN nurse and ER nurse get verbal confirmation from an ER charge in relation to completion of trans-
portation call. Every CAN should have two days of a supervised orientation on all hospital units plus three ER days before working within
different departments. Assumptions might be made that every health care staff intends to offer patients the best care. Every care giver wishes

the best outcomes without any patients falling. Evaluation of Technology Aimed at Increasing Patient Safety

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The technologies on quality improvement have been implemented to enhance patient safety plus prevention of inpatient falls. The SRMC facili-
ty purchased beds having a three – mode sensitivity alarm for exit. It has also employed utilization of pads that are weight-sensitive which get
placed on commodes, chairs, and beds. After activation of the device, an alarm sounds within the nurse’s station and patient room. The
alarms for bed exit are situated under the patient’s buttock and shoulder level. This technology application for patients with decreased mobili-
ty, changed mental status and frequent toileting plus falls history light increase their safety. Basic outcome measure to assess technologies
happens to be incident rate per a thousand patient days for the patient falls, falls with crucial injury and falls with any given injury (Schildmei-
jer, et.al, 2018). Inpatient rehabilitation, nursing facilities and hospitals may integrate extra solutions alongside bed exit alarms for fall preven-
tion. Though most institutions use sitters, the video monitoring is most effective in minimizing inpatient falls. In addition, implementation of an
assessment on a fall risk plus patient centered education is one that enhances patient safety. Relevant Metrics Supporting Need for Improve-

ment

Inpatient falls national benchmarks range from 3.44 – 11.5 falls per 1000 patients on surgical, medical surgical units plus general medical
with approximated expenses of over $7000 for every injury. The rates of falls vary in hospitals by type of unit. Present fall rate on general med-
ical unit at the hospital is at 7.6 falls/1000 patients in comparison to 1.3 falls/1000 patients at the intensive care unit, and the 3.4 falls/1000 pa-
tients at the surgical unite. The SRMC falls metrics shows that the fall assessment device, patient safety procedures, policies, technologies plus
fall prevention are unsuccessful. As per the SRMC and national data, AHRQ reports that in between 700,000 and a million individuals within US
fall in hospitals. ⅓ of the falls can be prevented through managing the patients underlying risk factors of a fall, plus optimizing the physical de-
sign of the hospital plus the environment. The General inspector’s office had a study demonstrating 13.5% of the Medicare patients experienc-
ing an adverse effect that is preventable annually. The presented data is quite accurate. SRMC gathers falls data from electronic health
records and the reporting system of the hospital. The data gets forwarded to the National Database of Nursing Quality Indicators. Lastly, the
data becomes nationally available for validation of patient safety plus quality initiatives. Proposed Quality Initiative to Improve Patient

Safety

The element of safety culture is considered foundation of SRMCs program for fall prevention. Institutional wide education takes place during
orientation of new staff plus during yearly competency blitz. The facility had Morse Fall Scale incorporated into the HER, for alerting every med-
ical professional of any risk score. Now, reviews on post-falls are performed by different directors due to open positions for the Compli-
ance Officer and Quality Director. There lacks a consistency standard in post-fall assessments. Extra inconsistencies from a fall protocol consti-
tute of bed alarms, bed assignment plus nurse hand off amidst shifts. Rehabilitation and nursing facilities tackle the patient falls through use
of comparable interventions. Use of fall mats, exit alarms and lowering of beds to the floor are popular interventions (Sobieraj, et.al,
2019). Present literature prices that having video monitoring on an inpatient fall program decreases falls while enhancing patient safety.

The hospital showed a 100% fall decrement in the six weeks project, previous rate of fall was at 2.6 falls per 1000 patients. QI project con-
stituted of staff education, VM implementation for high-risk populations plus reassessing the present fall protocol. VM related successful inter-
ventions include behavior supervision, redirecting patients and having nurses notified through overhead paging system. The suggested
solutions to minimize future hospital inpatient falls are, creating a practice team that is evidence-based to evaluate the present fall protocol
plus processes. Second is evaluating whether bed plus alarm exit pads is appropriately employed consistently all over the departments. Third
is use of evidence-based practice team in development of a VM program as am intervention of QI in fall prevention. Lastly, have the VM pro-
gram outcomes measured through analyzing the fall rates, rule out the effective components then advance the essential processes (Murphy,
et.al, 2021). Most healthcare institutions depend on alarms only in prevention of patient falls. Conflicting data like HACs non-payment by CMS,
rates of falls plus consistent attempts in falls prevention is still in existence. Additional perspectives on enhancing patient safety plus decreas-

ing falls includes educating families and patients on falls. Conclusion

Patient falls are adverse events that can be avoided. The QI initiatives aid in preventing inpatient falls while enhancing patient safety. It is

essential to adopt a safety culture at an institution one involving family, support staff, patients, leadership plus the healthcare givers.

References

Lee, S. E., Vincent, C., Dahinten, V. S., Scott, L. D., Park, C. G., & Dunn Lopez, K. (2018). Effects of individual nurse and hospital charac-
teristics on patient adverse events and quality of care: A multilevel analysis. Journal of Nursing Scholarship, 50(4), 432-440. https://sigmapub-
s.onlinelibrary.wiley.com/doi/abs/10.1111/jnu.12396 Murphy, A., Griffiths, P., Duffield, C., Brady, N. M., Scott, A. P., Ball, J., & Drennan, J.
(2021). Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings. Journal of
advanced nursing, 77(8), 3379-3388. https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.14860 Schildmeijer, K. G. I., Unbeck, M., Ekst-
edt, M., Lindblad, M., & Nilsson, L. (2018). Adverse events in patients in home healthcare: a retrospective record review using trigger tool
methodology. BMJ open, 8(1), e019267. https://bmjopen.bmj.com/content/8/1/e019267.abstract Sobieraj, D. M., Martinez, B. K., Hernan-
dez, A. V., Coleman, C. I., Ross, J. S., Berg, K. M.,. & Baker, W. L. (2019). Adverse effects of pharmacologic treatments of major depres-
sion in older adults. Journal of the American Geriatrics Society, 67(8), 1571-1581. https://agsjournals.onlinelibrary.wiley.-
com/doi/abs/10.1111/jgs.15966

22 33

44
44 55

44 66
66

77
88 99

1 01 0

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S o u r c e M a t c h e sS o u r c e M a t c h e s ( (3 73 7))

Student paper 68%

Student paper 100%

Student paper 73%

Student paper 64%

Student paper 66%

Student paper 63%

Student paper

According to Centers for Disease Control and Prevention one among four
adults who are older fall annually, one among the five falls results into major
injury. This paper is an adverse event of a comprehensive review during the
professional writing career of the writer.

Original source

The Centers for Disease Control and Prevention (CDC) report that one in four
older adults fall each year, and one in five falls cause serious injury (CDC,
n.d.) The following is a comprehensive review of an adverse event (AE) during
this writer’s professional nursing career

Student paper

Analysis of an Adverse Event

Original source

Analysis of an Adverse Event

Student paper

Her medical recent history noted a complete surgery at the right hip in under
two weeks before and got rehabilitation therapy. Ms Linda was diagnosed
with kidney injury as well as severe sepsis all linked to an infection within the
urinary tract.

Original source

Recent medical history noted a total right hip surgery less than two weeks
prior and received rehabilitation therapy Ms Jones was diagnosed with severe
sepsis and kidney injury related to urinary tract infection

Student paper

The Ms Linda fall was because of medical management and not sepsis, the
underlying condition.

Original source

The fall that Ms Jones suffered due to medical management rather than her
underlying condition of sepsis

Student paper

The patient was all alone in her room without supervision, while the nurse
was not aware of Ms Linda’s arrival. Deviations from the known admission
protocol for new patients caused the AE.

Original source

The patient was left alone in her room with no supervision, and the nurse re-
ported no knowledge of the arrival of Ms Jones Deviations from the estab-
lished protocol for admission of new pts’ let to the AE

Student paper

If the Fall risk assessment was completed, it would have noticed Ms Linda to
be a Fall risk.

Original source

Completing the fall risk assessment would have identified Ms Jones as a fall
risk

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Student paper 64%

Student paper 77%

Student paper 81%

Student paper 69%

Student paper 77%

Student paper 93%

Student paper

Report from Healthcare Research and Quality Agency states that 1.6 million
residents of nursing homes, around 50% fall yearly.

Original source

The Agency for Healthcare Research and Quality reports that of the 1.6 mil-
lion nursing home residents, approximately half fall annually (AHRQ, n.d.)

Student paper

Fall education knowledge gaps might exist in between organizational
departments.

Original source

Knowledge gaps in fall education may exist between departments in the
organization

Student paper

Implications of Falls for All Stakeholders Every stakeholder experiences long
and short-term ramifications die to inpatient falls.

Original source

Implications of Falls for All Stakeholders All stakeholders experience short
and long-term ramifications because of inpatient falls

Student paper

On top of a lengthy hospital stay, long term effects comprise of, community
and personal loss of faith within delivery of health care. The discovery is that
the AE involved interdisciplinary team suffers from depression, anxiety plus a
life quality that is decreased. The health care experts might as well suffer so-
cial isolation, diminished professional confidence in addition to legal
considerations.

Original source

In addition to a more extended hospital stay, the long-term effects include in-
dividual and community loss of faith in health care delivery (2017) have dis-
covered that the interdisciplinary team involved with the AE has been known
to suffer from anxiety, depression, and a decreased quality of life Health care
professionals may also suffer legal considerations, social isolation, and di-
minished professional confidence

Student paper

The Medicaid and Medicare Services centers has inpatient falls included as a
hospital-acquired condition that is non-reimbursable. The same way, addi-
tional extended hospital stays and extra resources to offer services for inpa-
tient falls get included within the cumulative revenue loss.

Original source

The Centers for Medicare & Medicaid Services (CMS) have included inpatient
falls as a non-reimbursable hospital-acquired condition (Hospital-acquired
Conditions, n.d.) Similarly, the more extended hospital stays and additional
resources to provide services for inpatient falls are included in the cumulative
loss of revenue

Student paper

Falls reflect system failures within organizational processes and structures.

Original source

Falls reflect system failures in organizational structures and processes

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Student paper 64%

Student paper 74%

Student paper 64%

Student paper 79%

Student paper 69%

Student paper

Patients tend to have gaps within perceived fall risks plus falls commonality.

Original source

(2020) discovered that pts’ have gaps in perceived fall risks and commonality
of falls

Student paper

The staffing supervisor measures might have had the AE prevented.

Original source

Measures taken by the staffing supervisor may have prevented this AE

Student paper

Every CAN should have two days of a supervised orientation on all hospital
units plus three ER days before working within different departments. As-
sumptions might be made that every health care staff intends to offer pa-
tients the best care.

Original source

Furthermore, all CNAs must complete two days of supervised orientation on
each hospital unit and three days in the ER prior to working in different de-
partments Assumptions can be made that all health care staff want to pro-
vide the best possible care to pts

Student paper

Evaluation of Technology Aimed at Increasing Patient Safety The technologies
on quality improvement have been implemented to enhance patient safety
plus prevention of inpatient falls. The SRMC facility purchased beds having a
three – mode sensitivity alarm for exit. It has also employed utilization of
pads that are weight-sensitive which get placed on commodes, chairs, and
beds.

Original source

Evaluation of Technology Aimed at Increasing Patient Safety Quality Improve-
ment (QI) technologies have been put in place to increase patient safety and
prevent inpatient falls SRMC has purchased hospital beds with a three-mode
sensitivity exit alarm In addition, the hospital also employs the use of weight-
sensitive pads that are placed on beds, chairs, and commodes

Student paper

The alarms for bed exit are situated under the patient’s buttock and shoulder
level. This technology application for patients with decreased mobility,
changed mental status and frequent toileting plus falls history light increase
their safety. Basic outcome measure to assess technologies happens to be
incident rate per a thousand patient days for the patient falls, falls with cru-
cial injury and falls with any given injury (Schildmeijer, et.al, 2018). Inpatient
rehabilitation, nursing facilities and hospitals may integrate extra solutions
alongside bed exit alarms for fall prevention.

Original source

Bed exit alarms are positioned under the patient at the shoulder and buttock
level Application of this technology for pts’ experiencing frequent toileting,
decreased mobility, history of falls, and altered mental status can increase
patient safety (Cournan et al., 2018 The primary outcome measure to evalu-
ate technologies is the incident rate per 1000 patient days (PDs) for patient
falls, falls with any injury, and falls with serious injury (Falls Dashboard, 2020)
Hospitals, inpatient rehabilitation, and nursing facilities can integrate addi-
tional solutions along with bed exit alarms to prevent pt falls

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Student paper 72%

Student paper 73%

Student paper 89%

Student paper 71%

Student paper 63%

Student paper 74%

Student paper

Inpatient falls national benchmarks range from 3.44 – 11.5 falls per 1000 pa-
tients on surgical, medical surgical units plus general medical with approxi-
mated expenses of over $7000 for every injury. The rates of falls vary in hos-
pitals by type of unit. Present fall rate on general medical unit at the hospital
is at 7.6 falls/1000 patients in comparison to 1.3 falls/1000 patients at the in-
tensive care unit, and the 3.4 falls/1000 patients at the surgical unite. The
SRMC falls metrics shows that the fall assessment device, patient safety pro-
cedures, policies, technologies plus fall prevention are unsuccessful.

Original source

Relevant Metrics Supporting Need for Improvement National benchmarks for
inpatient falls range from 3.44 to 11.5 falls/1000 PDs on general medical, sur-
gical, and medical-surgical units, with estimated costs exceeding $7000 per
injury Falls rates in hospitals vary by unit type (Bouldin et al., 2013 The cur-
rent fall rate on the GMU at SRMC is 7.6 falls per/1000 PDs as compared to
1.3 falls per/1000 PDs on the intensive care unit (ICU), and 3.4 falls per/1000
PDs on the surgical unit (SU) These fall metrics from SRMC suggest the tech-
nologies, fall assessment tool, policies, and procedures for patient safety and
fall prevention are not successful

Student paper

The presented data is quite accurate. SRMC gathers falls data from electronic
health records and the reporting system of the hospital. The data gets for-
warded to the National Database of Nursing Quality Indicators.

Original source

The data presented is relatively accurate First, SRMC collects falls data from
the hospital reporting system and electronic health record (EHR) The national
database of nursing quality indicators (NDNQI®)

Student paper

Proposed Quality Initiative to Improve Patient Safety The element of safety
culture is considered foundation of SRMCs program for fall prevention.

Original source

Proposed Quality Initiative to Improve Patient Safety The culture of safety ele-
ment is the foundation of the fall prevention program at SRMC

Student paper

Now, reviews on post-falls are performed by different directors due to open
positions for the Compliance Officer and Quality Director.

Original source

Currently, post-fall reviews are conducted by various directors because of
open positions for the Director of Quality and Compliance Officer

Student paper

Use of fall mats, exit alarms and lowering of beds to the floor are popular in-
terventions (Sobieraj, et.al, 2019).

Original source

Utilization of fall mats, lowering the bed to the floor, and exit alarms are not-
ed as common interventions

Student paper

QI project constituted of staff education, VM implementation for high-risk
populations plus reassessing the present fall protocol.

Original source

The QI project included education of staff, implementation of VM for high-
risk populations, and re-evaluating the current fall protocol

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Student paper 66%

Student paper 65%

science 68%

Student paper 82%

Student paper 100%

Student paper

The suggested solutions to minimize future hospital inpatient falls are, creat-
ing a practice team that is evidence-based to evaluate the present fall proto-
col plus processes.

Original source

Proposed solutions to prevent future inpatient hospital falls include forming
an evidence-based practice team to analyze the current fall protocol and
processes

Student paper

Patient falls are adverse events that can be avoided. The QI initiatives aid in
preventing inpatient falls while enhancing patient safety.

Original source

Patient falls are avoidable adverse events QI initiatives will help prevent inpa-
tient falls and improve patient safety

Student paper

S., Scott, L.

Original source

Scott, Jennifer L

Student paper

Effects of individual nurse and hospital characteristics on patient adverse
events and quality of care:

Original source

I am writing in regard to the article “Effects of Individual Nurse and Hospital
Characteristics on Patient Adverse Events and Quality of Care

Student paper

M., Scott, A. P., Ball, J., & Drennan, J.

Original source

M., Scott, A P., Ball, J., & Drennan, J

Student paper

Estimating the economic cost of nurse sensitive adverse events amongst pa-
tients in medical and surgical settings.

Original source

Estimating the economic cost of nurse sensitive adverse events amongst pa-
tients in medical and surgical settings

Student paper

Journal of advanced nursing, 77(8), 3379-3388.

Original source

Journal of Advanced Nursing, 77(8), 3379-3388

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Student paper 70%

Student paper 93%

Student paper 100%

Student paper 66%

science 67%

Student paper 100%

Student paper 82%

Student paper

https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.14860 Schildmeijer, K.

Original source

Retrieved November 19, 2021, from
https://onlinelibrary.wiley.com/doi/full/10.1111/jan.14860

Student paper

I., Unbeck, M., Ekstedt, M., Lindblad, M., & Nilsson, L.

Original source

S., Unbeck, M., Ekstedt, M., Lindblad, M., & Nilsson, L

Student paper

Adverse events in patients in home healthcare: a retrospective record review
using trigger tool methodology.

Original source

Adverse events in patients in home healthcare A retrospective record review
using trigger tool methodology

Student paper

BMJ open, 8(1), e019267.

Original source

2018;8(1):e019267

Student paper

I., Ross, J.

Original source

Fleischman, Ross J

Student paper

Adverse effects of pharmacologic treatments of major depression in older
adults.

Original source

Adverse Effects of Pharmacologic Treatments of Major Depression in Older
Adults

Student paper

https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15966

Original source

https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.12440

Adverse Event or Near-Miss Analysis – 5 pages

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