Assessment 1 Adverse Event or Near Miss Analysis Student Name Capella University Course Name Prof Name June 13 2024 Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us Contact bsnwritingservices com Website BSNWritingservices com For Free MSN Sample BSNWritingservices com free Sample Adverse Event or Near Miss Incident Analysis Presentation Adverse events AEs or near miss incidents are common in healthcare settings Adverse events are defined as undesirable outcomes resulting from preventable actions or clinical interventions that compromise patient safety and well being Schwendimann et al 2018 Near miss events are incidents that had they occurred could have caused harm or injury to patients Yang Liu 2021 Research spanning 27 countries on six Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us Contact bsnwritingservices com Website BSNWritingservices com For Free MSN Sample BSNWritingservices com free Sample continents shows that around 10 of hospital patients experience adverse events with 7 3 being severe and 34 83 being preventable Schwendimann et al 2018 More than 250 000 patients face complications during treatment resulting in over 100 000 deaths due to care related issues Skelly et al 2022 Analysis of the Missed Steps Protocol Deviations and Knowledge Gaps Studies indicate that hospitalized patients regardless of their illness are at risk of falls according to risk assessment tools LeLaurin Shorr 2019 Patients with recent heart attacks and the geriatric population particularly post operative have an elevated fall risk Dworsky et al 2021 Manemann et al 2018 In Michelle s case the frontline nurse Kellyn failed to identify the patient s fall risk score indicating a knowledge gap and a lack of task prioritization Additionally the nurse lacked awareness of the patient s environment and fall preventive measures Nurse managers should establish policies to prevent protocol deviations and maintain patient safety The Morse Fall Scale MFS a globally accepted fall risk assessment tool categorizes patients into low medium and high risk levels based on six criteria Kim et al 2021 Healthcare providers must enhance their knowledge of risk assessment skills to ensure patient safety Key missing information includes why Nurse Kellyn did not adequately monitor her patients the actions of other healthcare providers family inaction and whether the patient was informed about fall risk prevention measures Answers to these questions would assist in a more comprehensive analysis of the root causes of the incident Analysis of the Implications for the Stakeholders Stakeholders including patients family members nurses and hospital administration play crucial roles in healthcare Adverse events negatively affect patients and their families and legal repercussions create a vulnerable environment for hospital administration Poor outcomes include a decline in hospital reputation and diminished healthcare quality Baris Seren Intepeler 2018 Effective collaboration among stakeholders is essential for quality healthcare All stakeholders share responsibility for errors in clinical practices and should work together to prevent adverse events Healthcare organizations such as Miami Valley Hospital must establish measures to minimize adverse events and their impacts Quality Improvement Actions and Technologies Various fall prevention strategies and quality improvement initiatives are recommended such as identifying at risk patients alarms sitters patient education environmental modifications restraints and non slip socks LeLaurin Shorr 2019 Portable video Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us Contact bsnwritingservices com Website BSNWritingservices com For Free MSN Sample BSNWritingservices com free Sample monitoring PVM during nighttime is a technological intervention that has shown progress in reducing falls Woltsche et al 2022 Evaluation metrics for these actions and technologies include analyses of falls before and after implementation patient education cost effectiveness ease of use for nurses and nurse training Morat et al 2023 Montero Odasso et al 2021 Outline for a Quality Improvement Initiative Lean Six Sigma LSS is a methodology that can enhance the capability and efficacy of processes in healthcare settings The DMAIC approach Define Measure Analyze Improve Control is a five step methodology to guide improvement efforts Tufail et al 2022 Quality improvement strategies may involve team changes staff education frequent audits and feedback and patient education Tricco et al 2019 The implementation of these strategies should be continuously monitored and sustained for long term effectiveness Conclusion Ensuring patient safety and quality improvement in healthcare is challenging but crucial Quality improvement initiatives including the use of assessment tools staff and patient education and technological interventions are essential for addressing the root causes of adverse events Effective collaboration among stakeholders and the implementation of these measures will contribute to improved patient safety and healthcare quality Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us Contact bsnwritingservices com Website BSNWritingservices com For Free MSN Sample BSNWritingservices 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 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