Prepare an analysis (5-7 pages) of an adverse event or a near miss from your professional nursing experience and outline a QI initiative that would address it. Introduction 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. Overview The goal of this assessment is to allow you to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a QI initiative to prevent future incidents. It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself in as a health care professional. Health care organizations strive for a culture of safety. Yet, despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation, and regulations, medical errors continue to occur. 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. Historically, medical errors were reported and analyzed in hindsight. Today, QI initiatives attempt to be proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by new technologies and reporting metrics, adverse events and near misses can provide insight into potential ways to improve care delivery and ensure patient safety. For clarification, the National Quality Forum (n.d.) defines the following: Adverse event: An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient. Near miss: An event or a situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention. Prepare a comprehensive analysis of an adverse event or a near miss from your professional nursing experience that you or a peer experienced. Provide an analysis of the impact of the same type of adverse event or near miss in other facilities. How was it managed, who was involved, and how was it resolved? Be sure to: Analyze the implications of the adverse event or near miss for all stakeholders. Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis. Evaluate QI actions or technologies related to the event that are required to reduce risk and increase patient safety. Evaluate how other institutions integrated solutions to prevent these types of events. Incorporate relevant metrics of the adverse event or near miss to support need for improvement. Outline a QI initiative to prevent a future adverse event or near miss. Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards. Be sure your analysis addresses all of the above points. You may also want to read the Adverse Event or Near Miss Analysis Scoring Guide to better understand the performance levels that relate to each grading criterion.
Health care organizations are committed to ensuring patient safety by fostering a culture of safety and implementing various measures to prevent adverse events and near misses. Despite these efforts, medical errors still occur, affecting patients and healthcare providers alike. In this essay, we will analyze an adverse event from a professional nursing experience, discuss its implications for all stakeholders, conduct a root cause analysis, evaluate quality improvement actions and technologies, examine how other institutions addressed similar events, incorporate relevant metrics, and outline a quality improvement (QI) initiative to prevent future adverse events or near misses.
Adverse Event Description
The adverse event in question occurred in a surgical ward where I was working as a registered nurse. A patient who had undergone abdominal surgery developed a surgical site infection (SSI) postoperatively. The patient exhibited signs of infection, including redness, swelling, and purulent drainage from the surgical incision site. The healthcare team initiated antibiotic therapy promptly, but the infection progressed, requiring surgical intervention to drain an abscess.
Implications for Stakeholders
The adverse event had significant implications for various stakeholders. Firstly, the patient experienced prolonged hospitalization, increased pain and discomfort, and the need for additional surgical procedures, leading to emotional distress. Additionally, the patient’s family was emotionally affected and concerned about the quality of care provided. The healthcare providers involved, including the surgical team and nursing staff, faced feelings of guilt and anxiety (James et al., 2017). The hospital’s reputation was also at stake, as such events could lead to decreased patient trust (Gustafsson et al., 2019).
Sequence of Events and Root Cause Analysis
The sequence of events leading to the adverse event involved missed steps and protocol deviations. Upon reviewing the case, it was identified that the following root causes contributed to the adverse event:
Inadequate hand hygiene: Several instances of inadequate hand hygiene were observed among healthcare providers during patient care activities, potentially introducing pathogens to the surgical site (Allegranzi & Pittet, 2017).
Lack of standardized wound care protocols: There was no standardized protocol for wound care and assessment, leading to variations in practice and potential oversights in identifying early signs of infection (Berríos-Torres et al., 2017).
Communication breakdown: Communication between the nursing staff and the surgical team was insufficient, resulting in delayed recognition of the worsening infection (Cohen et al., 2020).
QI Actions and Technologies
To reduce the risk of similar adverse events in the future and enhance patient safety, several QI actions and technologies are recommended:
Enhanced Hand Hygiene Education: Implement mandatory hand hygiene training for all healthcare providers, emphasizing its critical role in preventing healthcare-associated infections (WHO, 2019).
Standardized Wound Care Protocols: Develop and implement evidence-based wound care protocols that clearly outline assessment criteria and interventions for surgical site infections (CDC, 2020).
Interdisciplinary Communication: Establish regular interdisciplinary team meetings to promote effective communication and collaboration among healthcare providers, ensuring early recognition and response to patient issues (Agency for Healthcare Research and Quality, 2018).
Electronic Health Records (EHR) Alerts: Integrate EHR systems with alerts for surgical site infection risk factors, prompting healthcare providers to conduct timely assessments and interventions (Wu et al., 2022).
Integration of Solutions in Other Institutions
Other healthcare institutions have integrated various solutions to prevent similar adverse events. They have adopted electronic surveillance systems for early infection detection, implemented standardized infection prevention bundles, and conducted regular quality audits to identify areas for improvement (Allegranzi & Zayed, 2020).
To support the need for improvement, relevant metrics should be collected and analyzed. These metrics may include SSI rates, compliance with hand hygiene protocols, time to surgical site infection recognition, and patient satisfaction scores (Fakih et al., 2017).
Outline of QI Initiative
The proposed QI initiative to prevent future adverse events or near misses related to surgical site infections includes the following steps:
Establish a multidisciplinary QI team consisting of nurses, surgeons, infection control specialists, and quality improvement experts.
Conduct a baseline assessment of current hand hygiene compliance rates and the incidence of surgical site infections within the organization.
Develop evidence-based, standardized wound care protocols and educational materials for healthcare providers.
Implement mandatory hand hygiene training and ongoing monitoring, with a focus on observed compliance (Allegranzi & Pittet, 2017).
Enhance interdisciplinary communication through regular meetings and the use of electronic communication tools (Cohen et al., 2020).
Integrate EHR alerts for surgical site infection risk factors, ensuring timely assessment and intervention (Wu et al., 2022).
Establish a continuous monitoring and feedback system to track progress and make necessary adjustments (Agency for Healthcare Research and Quality, 2018).
Adverse events and near misses in healthcare settings can have profound consequences for patients, their families, and healthcare providers. By conducting a thorough analysis of such events and implementing quality improvement initiatives, healthcare organizations can proactively work towards preventing future occurrences and enhancing patient safety. The proposed QI initiative outlined here provides a structured approach to addressing the root causes of adverse events, ultimately leading to improved patient outcomes and a safer healthcare environment.
Agency for Healthcare Research and Quality. (2018). TeamSTEPPS.
Allegranzi, B., & Pittet, D. (2017). Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection, 95(3), 281-282.
Allegranzi, B., & Zayed, B. (2020). The burden of healthcare-associated infections in the Middle East: A systematic review and meta-analysis. Journal of Infection and Public Health, 13(6), 889-896.
Berríos-Torres, S. I., et al. (2017). Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surgery, 152(8), 784-791.
CDC. (2020). Surgical site infection (SSI) event.
Cohen, M. M., et al. (2020). Change management in healthcare: Literature review and key components. Healthcare Policy, 16(2), 104-120.
Fakih, M. G., et al. (2017). The impact of mandatory public reporting of healthcare-associated infections on infection rates in critical care. Clinical Infectious Diseases, 65(11), 1902-1909.
Gustafsson, L., et al. (2019). Patients’ perceptions of quality of care at an emergency department and identification of areas for quality improvement. Journal of Patient Experience, 6(4), 332-340.
Huang, S. S., et al. (2018). Targeted versus universal decolonization to prevent ICU infection. New England Journal of Medicine, 368(24), 2255-2265.
Frequently Asked Questions (FAQ)
1. What is the purpose of analyzing nursing adverse events and proposing quality improvement initiatives?
- The purpose is to enhance patient safety by identifying the causes of adverse events, learning from them, and developing strategies to prevent similar incidents in the future.
2. What are adverse events and near misses in healthcare?
- Adverse events are incidents that result in unintended harm to patients due to actions or omissions unrelated to the underlying disease or condition. Near misses are events that could have harmed patients but didn’t, often due to timely intervention or other factors.
3. How can adverse events impact patients and healthcare providers?
- Adverse events can lead to prolonged hospitalization, increased pain, additional medical procedures, emotional distress for patients and their families, and psychological stress for healthcare providers.
4. What are some common root causes of adverse events in healthcare?
- Common root causes may include inadequate hand hygiene, lack of standardized protocols, communication breakdowns, and deviations from established procedures.
5. What are the recommended quality improvement actions and technologies to prevent adverse events?
- Recommended actions include enhanced hand hygiene education, standardized protocols, interdisciplinary communication, and the integration of electronic health records (EHR) alerts. Technologies such as EHR systems play a crucial role in improving patient safety.
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