NURS FPX 6016 Assessment 1: Adverse Event or Near-Miss Analysis

Adverse Event or Near-Miss Analysis

The near-miss incidents and adverse events are very important to healthcare businesses because they pose a serious risk to the safety of patients. Adverse events are clinical problems that are not related to the patient’s starting condition. Similar negative events include extending a stay in a sanitarium, causing damage that can’t be undone, and taking life-saving measures to help someone die. In contrast, near-miss incidents provide essential literacy opportunities by exposing narrowly averted hazards. Feng et al. (2022) say that every year, hospitals around the world have 134 million bad events that cause 2.6 million deaths.

Similar alarming statistics show how often and how bad the situation is, with cases like falls, drug crimes, pressure injuries, and infections acquired in a sanitarium. These things happen a lot because healthcare workers aren’t as alert as they should be. If people are aware and follow safety rules, all of these things can be avoided or at least made less likely to happen. This case review will analyze the incident of a specific patient fall at Springfield General Hospital, addressing its challenges and offering pragmatic recommendations to mitigate the likelihood of recurrence in the future.

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis 

John is a 72-year-old man who was admitted to the sanitarium after having surgery to replace his right knee. He had a history of type 2 diabetes mellitus and mild cognitive impairment. His vital signs were stable when he was admitted: BP 130/78, HR 75, and RR 16. After the surgery, John was given painkillers and told to go to physical therapy. The head nanny of the orthopedic unit, Nanny Clara, did the first fall threat assessment, but she didn’t update it when John said he felt dizzy after moving from his bed to his president. Clara still made Mia, the worst nanny, help John walk to the bathroom while holding on tightly to the four-way. There was a delay in responding to the call light because Mia was busy with another case.

John, on the other hand, didn’t want to stay in bed, so he tried to get up by himself to go to the bathroom. He fell because he wasn’t steady on his feet and hit his forehead on the floor. The staff quickly helped John, who was confused and bleeding from a cut on his forehead. A CT scan showed that John had a mild concussion, which meant he had to stay in the hospital for five more days. John’s family was angry with the staff at the sanitarium after the incident because they didn’t take the fall-prevention protocol seriously. They filed a complaint against the sanitarium for not doing their job right.

Analysis of Implications of Adverse Event on Stakeholders

The bad thing that happened when John fell at Springfield General Hospital had a lot of different effects on everyone involved. In the short term, John had physical injuries, a longer recovery time, and emotional pain; in the long term, he had less mobility, more dependence, and the fear of falling again. His family went through emotional turmoil, financial stress, and a loss of faith in the healthcare system. The incident caused more stress, scrutiny, and possible criticism of the interprofessional team’s bad communication and safety practices. The effect on the sanitarium’s standing included damage to its reputation, unpaid bills, and spending money on fixes. The community’s trust in the sanitarium’s safety rules was also hurt, and this could affect people who want to get health care.

Assuming that the event was caused by problems with communication, poor case monitoring, and not following safety rules closely enough. There is also a strong belief that the incident could have been avoided if the staff had followed a good fall-prevention plan that included regular risk assessments and clear communication. Liabilities encompass performing a root cause analysis, providing immediate care, and openly discussing the incident with the case and family. Preventative measures, such as providing essential training to staff, timely responses to case demands, and advancements in attestation, are linked to the prevention of future incidents (WHO, 2020). This case emphasizes the interconnectedness of various stakeholders and their collective demand for a comprehensive approach to patient safety.

The sequence of events, missed steps, and protocol deviations are critical to understanding the adverse event.

John’s fall was not caused by his condition but by changes in the operation. The missed critical way was not checking on John’s threat of falling again after he said he felt dizzy, the nurses not communicating well during the shift change, and the call light not being answered right away. Because of these problems, John tried to walk without being seen, which caused him to fall. Root cause analysis showed that there were problems with putting fall prevention protocols into action, such as keeping records and keeping an eye on things. The incident also showed that there weren’t any proactive steps taken to help John or teach him how important it is to ask for help. If protocols had been carefully followed, this would not have happened.

This incident was mostly caused by problems with communication between professionals. Clear and organized handoffs would have made it clear that the threat of cascade was higher with the shift coming up. The nurses and the physical therapy team working together would make it safer for him to move around. The absence of verified real-time opportunities and the failure to seize chances to mitigate John’s dizziness underscore deficiencies in knowledge, especially concerning the potential escalation of sudden symptoms like dizziness into a significant risk of cascade. There are still new questions, such as whether the staffing situation or workload caused the delayed response and whether the sanitarium’s fall-prevention training was good enough for the staff. Addressing these concerns could help us understand how to stop similar bad things from happening in the future.

Quality Improvement Actions and Technologies

To avoid bad things like falls, it will be important to use technologies and quality improvement practices that are based on evidence. One important step is to use validated tools like the Morse Fall Scale to do regular fall risk assessments on patients to find out which ones are at risk and how to best care for them (Kim et al., 2021). Staff members should participate in regular training sessions focused on fall-prevention protocols, which encompass clear pathways, appropriate footwear, and the availability of mobility aids. It is also very important to teach cases and families about safety measures and get them involved in fall prevention (WHO, 2020).

Another effective strategy is to create a culture of responsibility in healthcare, where everyone is responsible for covering and reporting safety issues. Hourly rounding and having call lights available are also good evidence-based ways to help reduce the risk of falls (Abraham, 2024). All of this behavior creates an environment that puts patient safety first and cuts down on unnecessary cascades.

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis 

Technology is a big part of stopping cascade. Tools like bedside warnings and patient-monitoring systems give people warnings that are ahead of their time. For example, pressure-sensitive beds and presidential alerts let staff know when high-risk patients try to move without help (Wen et al., 2024). Also, videotape monitoring systems can keep an eye on cases that are likely to cascade in real time. Electronic Health Records (EHRs) with decision-support systems can also help stop cascades by using real-time threat assessment and care planning (Jacobsohn et al., 2022).

These technologies need to be tested to see how well they work for crimes at Springfield General Hospital. Important factors would be the cascade before and after the crime, patient satisfaction scores, and how many times staff followed instructions (Morris et al., 2022). Monitoring the outgrowth always means improving, and it makes sure that the sanitarium’s safety business works toward public goals that later lower the number of falls and improve patient care.

Quality Improvement Initiative

We will use the Plan-Do-Study-Act (PDSA) framework to start a quality improvement project at Springfield General Hospital to make things better for future cases. In this case, the goal is to cut the number of outpatient cascades by 30 over the course of six months using a variety of methods. These include doing fall-threat assessments when someone is admitted, doing rounds during the day, and doing them again when there is a change in the case’s condition. The staff will learn how to prevent falls, and the sanitarium grounds will be changed to make sure there are no hidden dangers. The program will also include the option of hourly rounding. On the other hand, research shows that hourly rounding didn’t work, while other studies showed that it did work, especially when it was used with other treatments. We will take this difference into account when we use the same strategy at Springfield General Hospital (Boot et al., 2023).

The intervention will take place in an at-risk unit with bed admonitions, EHR-based warnings for at-risk cases, and interdisciplinary rounding. All staff members will follow the same safety protocol every time. The study gathers information on how common cascade is, how well patients understand it, and how well staff follow it. We will also compare these to the data from before the initiative to see how much of a difference the action made. It would also be important to think about negation, which is like alarm fatigue or being too reliant on technology.

The alarm system and the EHR warnings will help keep patients safe, but some workers may be too busy to pay attention to them too often, which could make them less sensitive or miss other warnings (Clodfelter, 2023). We will look at the results to see if the balance and effectiveness of addressing these issues are good. If there are any gaps, we may need to hire more staff or improve the training program. It will, however, be measured to include all departments in the sanitarium so that long-term improvements can be made in patient safety while respecting different views on the role of technology and workflows if the action is successful.

Conclusion

In conclusion, John’s fall at Springfield General Hospital was an unfortunate event that showed serious problems with communication, following safety rules, and keeping an eye on patients that could have been avoided. The sanitarium can significantly reduce fall incidents and improve patient safety by using the Plan-Do-Study-Act (PDSA) framework to implement a comprehensive quality improvement plan that includes fall-threat assessments, staff training, changes to the environment, and the use of technology, such as bed warnings and EHR warnings. This action could make healthcare safer by addressing hidden problems like alarm fatigue and finding a balance between technology and human oversight. To make sure that all staff members are on the same page when it comes to patient safety, strategies will need to be constantly evaluated and adjusted. The goal is to make these improvements across the entire sanitarium.

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis 

Feng, T., Zhang, X., Tan, L., Su, Y., & Liu, H. (2022). Near-miss organizational literacy in nursing within a tertiary sanitarium A mixed-styles study. BMC Nursing, 21(1). https://doi.org/10.1186/s12912-022-01071-1

Jacobsohn, G. C., Leaf, M., Liao, F., Maru, A. P., Engstrom, C. J., Salwei, M. E., Pankratz, G. T., Eastman, A., Carayon, P., Wiegmann, D. A., Galang, J. S., Smith, M. A., Shah, M. N., & Patterson, B. W. (2022). cooperative design and perpetration of a clinical decision support system for automated fall-threat identification and referrals in exigency departments. Healthcare, 10(1), 100598. https://doi.org/10.1016/j.hjdsi.2021.100598 

Kim, Y. J., Choi, K., Cho, S. H., & Kim, S. J. (2021). Validity of the Morse Fall Scale and the Johns Hopkins Fall Threat Assessment Tool for fall threat assessment in an acute care setting. Journal of Clinical Nursing, 31(23-24). https://doi.org/10.1111/jocn.16185 

Morris, M., Webster, K., Jones, C., Hill, A.-M., Haines, T., McPhail, S., Kiegaldie, D., Slade, S., Jazayeri, D., Heng, H., Shorr, R., Carey, L., Barker, A., & Cameron, I. (2022). Interventions to reduce cascades in hospitals The study conducted a methodical review and meta-analysis. Age and Ageing, 51(5), 1–12. https://doi.org/10.1093/ageing/afac077 

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis 

Wen, M.-H., Chen, P.-Y., Lin, S., Lien, C.-W., Tu, S.-H., Chueh, C.-Y., Wu, Y.-F., Tan, K., Hsu, Y.-L., & Bai, D. (2024). Enhancing patient safety through an intertwined internet of effects patient care system: a large quasi-experimental study on fall forestallment. Journal of Medical Internet Research, 26, e58380–e58380. https://doi.org/10.2196/58380 

World Health Organization (2020). Case safety incident reporting and literacy systems specialized report and guidance. https://www.who.int/publications/i/item/9789240010338