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

Assessment 1 Adverse Event or Near-Miss Analysis

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Capella University

NURS-FPX 6016 Quality Improvement of Inter-professional Care

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Date

Adverse Event or Near-Miss Incident Analysis

Adverse events (AEs) or near-miss incidences are very common in healthcare settings. Literature defines adverse events as undesirable outcomes of any preventable actions or medical intervention that leads to patients’ unsafety and harm them (Schwendimann et al., 2018) whereas near-miss events are those incidences which if occurred may have caused harm or injury to the consumers (Yang & Liu, 2021). A study conducted on 25 studies from 27 various countries across six continents revealed that around 10% of patients are affected by adverse events in hospitals out of which 7.3% of AEs were life-threatening. Furthermore, 34-83% of events were described as preventable events (Schwendimann et al., 2018). Further research estimates that more than 250,000 patients experience different adversities during their treatment and over 100,000 patients face deaths due to the care they receive (Skelly et al., 2022). Some of the preventable adverse events are nosocomial diseases, patients fall incidences, medication errors, and surgery-related adverse events. The focus of this adverse events analysis is on preventable falls in healthcare settings. The analysis will advocate strategies to alleviate these events based on a case of a patient’s fall observed in the Cardiovascular (CV) step-down unit at Miami Valley Hospital, a multispecialty hospital in the United States. 

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

Michelle, an 86-year-old female patient came to the hospital for her elective bypass grafting surgery. Her surgery went well and as usual, she was shifted to the CV step-down unit after 3 days of the operation. During her stay at the step-down unit, the physician regularly visited her to update her progress, nurses routinely administered her medication and nurse aids documented her vital monitoring methodically. One night on a busy hectic shift, nurse Kellyn was completing her documentation when suddenly she heard a loud sound as if someone fell on the ground. Upon checking her patients, she found patient Michelle had fallen on the floor from her bed. The patient was found collapsed for which an emergency rush call was announced, patient was immediately transferred to the bed, and code blue was initiated. This incident led the patient to face death. Further investigation revealed that the patient’s side rails were down and her bed level was kept elevated. Moreover, her bed wheels weren’t locked as well. Due to these allegations family imposed legal duties on the nurse and the hospital for their negligence which caused adverse events for the patient and the family. This event opened the eyes of nurses and healthcare administration to further examine the adverse events that occur in the hospital to prevent patient safety and for quality improvement (QI).

Analysis of the Missed Steps, Protocol Deviations, and Knowledge Gaps

The study reflects that all hospitalized patients regardless of their disease process falling under the criteria of risk assessment tools are considered to be at risk of falls (LeLaurin & Shorr, 2019). Further studies revealed that most of the hospitalized patients with recent cardiovascular incidences and the geriatric population who are post-operative have an elevated fall score, which can lead to readmissions and fatalities for the patients (Dworsky et al., 2021; Manemann et al., 2018). This evidence advocates the importance of fall prevention for elderly patients, post-operative and patients with cardiovascular diseases. Some of the analytical factors identified in this situation are:

1. The nurse being the frontline staff missed her responsibility of identifying her patients’ fall risk score according to the fall risk assessment scales and prioritizing nursing tasks according to the requirement. This incident recognizes that the nurse had a knowledge gap about the assessment scale and couldn’t find her patient’s risk factor which led to the sentinel event. 
2. The nurse wasn’t aware of her patient’s environment as well as fall preventive measures which led to this incident. 
3. Nurse managers/heads of departments should develop policies in this regard so that no protocols have deviated and patient safety is maintained. 

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

Although there are various scales established for identifying fall risks for patients in acute care settings, Morse Fall Scale (MFS) is one of the easy-to-use and globally accepted fall risk assessment tools utilized in tertiary care hospitals. This scale comprises 6 criteria: fall history (within 3 months), secondary diagnosis, use of ambulatory aid, IV/Heparin lock, gait/transferring, and mental status. Moreover, this scale categorizes patients into 3 levels (low risk- score 0 to 24, medium risk- score 25 to 44, and high risk- score 45 and higher) (Kim et al., 2021). Healthcare providers need to enhance their knowledge about risk assessment skills so that patient care and safety can be effectively ensured.  Some of the missing information and areas of uncertainty are why nurse Kellyn did not keep a check on her patients. What were other healthcare providers (doctors, nurse aids) doing? Why family did not take any action before the outcome? Was the patient informed about fall risk prevention measures? If these questions had answers, it would have been more beneficial in analyzing the situation and deriving a conclusion about the root causes which instigated this event. 

Analysis of the Implications for the Stakeholders

A group of stakeholders majorly play an important role in planning, decision-making, strategic and financial support, and implementation of quality care because healthcare is an inter-professional field and impacts all the stakeholders whether positively or negatively In this case, while patient and her family members are the first line of targets for having negatively impacted with this adverse event- death and loss of a loved one respectively, nurse and her team are also impacted undesirably due to the legal duties thus creating a vulnerable environment for hospital administration and other stakeholders to be impacted negatively- decline in hospital reputation and poor quality of healthcare (Baris & Seren Intepeler, 2018).

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

 These negative impacts have various implications for the stakeholders. Healthcare providers are responsible to provide effective care using preventive clinical practices in terms of preventing falls, team leaders and nurse managers should train their staff regarding fall prevention measures,  hospital administration and other policymakers should invest and establish policies for fall prevention to ensure patients safety is maintained and healthcare quality is improved (López-Soto et al., 2021). The assumptions about healthcare systems are 

• Effective collaboration among stakeholders is beneficial for quality health care (Laird et al., 2020). 
• All stakeholders are part of a high-risk environment thus they are equally responsible for any errors that occur in medical practices.
• Errors/mistakes make healthcare professionals vulnerable to job dissatisfaction hence leading to more serious adverse events (Baris & Seren Intepeler, 2018).

It is important for healthcare organizations like Miami Valley Hospital to establish measures to minimize these adverse events and their impacts by using various actions and technologies. 

Quality Improvement Actions and Technologies

Several guidelines present fall prevention interventions for patients in hospitals. For example, identify the patients who are at risk of falls and using clinical judgments to decide which fall prevention strategies will work in individual cases. Some of the fall prevention strategies and quality improvement actions presented by the research are identification of the fall risk patients (according to the guidelines by National Institute for Health and Care Excellence (NICE), every patient above the age of 65 and below 5 is considered high-risk for falls. While The Agency for Healthcare Research (AHRQ), recommends the utilization of assessment tools such as the Morse Scale to identify the vulnerable population), alarms (alarming systems designed to alert staff when the patient attempts to leave the chair/bed without assistance), sitters (companions who provide 1:1 surveillance to the patients), frequent rounds, patient education (risk of fall teaching, educational material- pamphlet, risk of fall bands), environmental modifications (bed wheels, side rails, call bells, bed level), restraints (side rails, physical restraints) and non-slip socks (LeLaurin & Shorr, 2019).

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

Recent research about quality improvement (QI) is focused on reducing human errors through the initiation of various technologies. One of the technologies is portable video monitoring (PVM) during nighttime. This study was conducted in Australia where PVM were installed in tertiary hospitals. These video cameras were alerted by noise as well as showed patients’ images on the screens which enabled nurses to hear and identify any unusual movements of the patients. This technology resulted in the reduction of around 72% of the fall rate in one ward. Hence it was concluded that portable video monitoring is effective fall prevention strategy (Woltsche et al., 2022).  Additionally, it is essential to evaluate these actions and technologies so that successful implementation is identified. Miami Valley Hospital should utilize some of these metrics to evaluate the strategies: a) comparison of falls before and after implementation of strategies, b) patients education, c) cost effectiveness, d) easy-to-use for nurses, e) nurse education (Morat et al., 2023; Montero-Odasso et al., 2021). 

Outline for a Quality Improvement Initiative 

The healthcare field has adapted various QI and measurement models over the years. One of these methodologies is Lean Six Sigma (LSS). This method, when implemented in a healthcare setting, helps to increase the capability and efficacy of any process by reducing defects and waste. A study conducted on LSS guides healthcare professionals to create an environment that is continuously improving and sustains the implementation of quality improvement strategies (Rathi et al., 2022). The MV Hospital can follow the model’s DMAIC approach. DMAIC is a five-step methodology to develop improvement: (a) define—identify issues (b) measure— understand current practices (c) analyze—recognize root causes of errors; (d) improve—introduce approaches and tools to increase quality (e) control—sustain them (Tufail et al., 2022). Some of the quality improvement strategies are 1. team changes—where organizational structure is changed by adding more team members and revising the professional roles and responsibilities 2. Staff education, 3. Frequent audits and feedback  4. Patient education (Tricco et al., 2019). 

Conclusion 

The process of Quality improvement and ensuring patient safety is challenging because healthcare organizations are required to keep a balance between quality healthcare and cost-effectiveness. Quality improvement initiatives, such as the utilization of the Morse assessment tool, staff education, patient education, and installation of portable video monitoring will help in fixing the root causes of patient falls. Effective collaboration among various stakeholders and initiative of all these measures will improve patient safety and help in quality improvement. 

References

Baris, V. K., & Seren Intepeler, S. (2018). Views of key stakeholders on the causes of Patient Falls and Prevention Interventions: A qualitative study using the International Classification of functioning, disability and health. Journal of Clinical Nursing, 28(3-4), 615–628. https://doi.org/10.1111/jocn.14656  Dworsky, J. Q., Shellito, A. D., Childers, C. P., Copeland, T. P., Maggard-Gibbons, M., Tan, H.-J., Saliba, D., & Russell, M. M. (2021). Association of Geriatric events with perioperative outcomes after elective inpatient surgery. Journal of Surgical Research, 259, 192–199. https://doi.org/10.1016/j.jss.2020.11.011   Kim, Y. J., Choi, K. O., Cho, S. H., & Kim, S. J. (2021). Validity of the Morse fall scale and the Johns Hopkins Fall Risk Assessment Tool for fall risk assessment in an acute care setting. Journal of Clinical Nursing, 31(23-24), 3584–3594. https://doi.org/10.1111/jocn.16185  Laird, Y., Manner, J., Baldwin, L., Hunter, R., McAteer, J., Rodgers, S., Williamson, C., & Jepson, R. (2020). Stakeholders’ experiences of the Public Health Research Process: Time to change the system? Health Research Policy and Systems, 18(1). https://doi.org/10.1186/s12961-020-00599-5  LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients. Clinics in Geriatric Medicine, 35(2), 273–283. https://doi.org/10.1016/j.cger.2019.01.007   López-Soto, P. J., López-Carrasco, J. de, Fabbian, F., Miñarro-Del Moral, R. M., Segura-Ruiz, R., Hidalgo-Lopezosa, P., Manfredini, R., & Rodríguez-Borrego, M. A. (2021). Chronoprevention in Hospital Falls of older people: Protocol for a mixed-method study. BMC Nursing, 20(1). https://doi.org/10.1186/s12912-021-00618-y   Manemann, S. M., Chamberlain, A. M., Boyd, C. M., Miller, D. M., Poe, K. L., Cheville, A., Weston, S. A., Koepsell, E. E., Jiang, R., & Roger, V. L. (2018). Fall risk and outcomes among patients hospitalized with cardiovascular disease in the community. Circulation: Cardiovascular Quality and Outcomes, 11(8). https://doi.org/10.1161/circoutcomes.117.004199 

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

Montero-Odasso, M. M., Kamkar, N., Pieruccini-Faria, F., Osman, A., Sarquis-Adamson, Y., Close, J., Hogan, D. B., Hunter, S. W., Kenny, R. A., Lipsitz, L. A., Lord, S. R., Madden, K. M., Petrovic, M., Ryg, J., Speechley, M., Sultana, M., Tan, M. P., van der Velde, N., Verghese, J., & Masud, T. (2021). Evaluation of clinical practice guidelines on fall prevention and management for older adults. JAMA Network Open, 4(12), e2138911. https://doi.org/10.1001/jamanetworkopen.2021.38911  Morat, T., Snyders, M., Kroeber, P., De Luca, A., Squeri, V., Hochheim, M., Ramm, P., Breitkopf, A., Hollmann, M., & Zijlstra, W. (2023). Evaluation of a novel technology-supported fall prevention intervention – study protocol of a multi-centre randomised controlled trial in older adults at increased risk of falls. BMC Geriatrics, 23(1). https://doi.org/10.1186/s12877-023-03810-8  Rathi, R., Vakharia, A., & Shadab, M. (2022). Lean six sigma in the healthcare sector: A Systematic Literature Review. Materials Today: Proceedings, 50, 773–781. https://doi.org/10.1016/j.matpr.2021.05.534   Skelly, C. L., Cassagnol, M., & Munakomi, S. (2022). Adverse events. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK558963/  Schwendimann, R., Blatter, C., Dhaini, S., Simon, M., & Ausserhofer, D. (2018). The occurrence, types, consequences and preventability of in-hospital adverse events – a scoping review. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-3335-z   Tufail, M. M., Shamim, A., Ali, A., Ibrahim, M., Mehdi, D., & Nawaz, W. (2022). DMAIC methodology for achieving public satisfaction with health departments in various districts of Punjab and optimizing CT scan patient load in Urban City Hospitals. AIMS Public Health, 9(2), 440–457. https://doi.org/10.3934/publichealth.2022030  

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

Tricco, A. C., Thomas, S. M., Veroniki, A. A., Hamid, J. S., Cogo, E., Strifler, L., Khan, P. A., Sibley, K. M., Robson, R., MacDonald, H., Riva, J. J., Thavorn, K., Wilson, C., Holroyd-Leduc, J., Kerr, G. D., Feldman, F., Majumdar, S. R., Jaglal, S. B., Hui, W., & Straus, S. E. (2019). Quality Improvement Strategies to prevent falls in older adults: A systematic review and network meta-analysis. Age and Ageing, 48(3), 337–346. https://doi.org/10.1093/ageing/afy219  Yang, Y., & Liu, H. (2021). The effect of patient safety culture on nurses’ near-miss reporting intention: The moderating role of perceived severity of near misses. Journal of Research in Nursing, 26(1-2), 6–16. https://doi.org/10.1177/1744987120979344   Woltsche, R., Mullan, L., Wynter, K., & Rasmussen, B. (2022). Preventing patient falls overnight using video monitoring: A clinical evaluation. International Journal of Environmental Research and Public Health, 19(21), 13735. https://doi.org/10.3390/ijerph192113735  

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