Prof Name Course Name Sept 14 2024 Student Name Capella University Assessment 1 Adverse Event or Near Miss Analysis MSNwritingservices com Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us Contact MSNwritingservices com Website MSNwritingservices com For Free MSN Sample MSNwritingservices com free Sample Examination of Adverse Events and Near Miss Incidents in Healthcare Settings MSNwritingservices com Hospitalized patients particularly the elderly and those recovering from cardiovascular events are at increased risk of falls In Michelle s case a significant lapse occurred when the frontline nurse failed to recognize her high fall risk score revealing a knowledge gap and a failure to prioritize safety measures Furthermore there was a general lack of awareness regarding the patient s condition and fall prevention protocols Nurse managers need to establish and reinforce protocols to prevent such deviations and ensure patient safety Adverse events AEs and near miss incidents are common challenges in healthcare settings posing significant risks to patient safety Adverse events refer to undesirable outcomes that occur due to preventable actions or clinical interventions jeopardizing patient well being Near misses on the other hand are incidents that could have caused harm but did not result in injury Studies indicate that approximately 10 of hospitalized patients worldwide experience adverse events with many being preventable This analysis focuses on preventable falls in healthcare environments highlighted by a case involving an 86 year old patient named Michelle who fell in the Cardiovascular CV step down unit during postoperative recovery at Miami Valley Hospital in the US Analyzing Missed Steps Protocol Deviations and Knowledge Gaps The Morse Fall Scale MFS a commonly used tool for assessing fall risk categorizes patients into low medium and high risk groups Improving healthcare providers proficiency in using such risk assessment tools is critical for reducing adverse outcomes Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us Contact MSNwritingservices com Website MSNwritingservices com For Free MSN Sample MSNwritingservices com free Sample Crucial missing details in this incident include why Nurse Kellyn did not sufficiently monitor her patients the roles of other healthcare staff family involvement and whether Michelle was informed about fall risk prevention strategies Answering these questions is essential for a thorough root cause analysis of the event Exploring Recommendations for Stakeholders Quality Improvement Initiatives and Innovations Evaluation metrics for these initiatives should assess changes in fall rates the effectiveness of patient education cost efficiency ease of use for nursing staff and the adequacy of nurse training Effective strategies for fall prevention include identifying at risk patients using alarms assigning sitters educating patients making environmental modifications using restraints carefully and providing non slip socks Technological solutions such as real time video monitoring PVM during nighttime have also been shown to reduce fall rates Stakeholders such as patients families nurses and hospital administrators all have key roles in healthcare Adverse events not only affect patients and their families but may also result in legal consequences harm the hospital s reputation and degrade the quality of care Collaboration among stakeholders is essential to prevent adverse events and mitigate their impacts MSNwritingservices com Applying the Lean Six Sigma LSS methodology particularly the DMAIC approach Define Measure Analyze Improve Control can significantly improve process efficiency and effectiveness in healthcare Quality improvement strategies may involve adjusting team roles educating staff conducting regular audits with feedback and providing patient education Ongoing monitoring and ensuring the sustainability of these improvements are crucial for long term success Improving patient safety and enhancing healthcare quality is vital Addressing the root causes of adverse events through quality improvement initiatives such as implementing assessment tools offering staff and patient education and adopting technological solutions is essential Collaboration among stakeholders and the adoption of these measures will lead to better patient safety and improved healthcare outcomes Framework for a Quality Improvement Initiative Conclusion Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us Contact MSNwritingservices com Website MSNwritingservices com For Free MSN Sample MSNwritingservices com free Sample 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 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 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 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 MSNwritingservices com 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 L pez Soto P J L pez Carrasco J de Fabbian F Mi arro Del Moral R M Segura Ruiz R Hidalgo Lopezosa P Manfredini R Rodr guez 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 Montero Odasso M M Kamkar N Pieruccini Faria F Osman A Sarquis Adamson Y Close J