Prof Name Course Name Student Name Capella University August 04 2024 Assessment 1 Adverse Event or Near Miss Analysis OnlineClassAssignment com Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us contact OnlineClassAssignment com Website OnlineClassAssignment com For Free MSN Sample OnlineClassAssignment com free Sample Introduction Evaluation of Adverse Events and Near Miss Incidents OnlineClassAssignment com Adverse events AEs and near miss incidents frequently occur in healthcare settings Adverse events are de ned as harmful outcomes resulting from preventable actions or procedures that compromise patient safety and well being Schwendimann et al 2018 In contrast near miss incidents involve situations that could have caused harm but ultimately did not result in actual injury Yang Liu 2021 Research across 27 countries reveals that about 10 of hospitalized patients encounter adverse events with 7 3 being life threatening and many considered preventable Schwendimann et al 2018 These events contribute signi cantly to adverse patient outcomes including over 100 000 deaths linked to care related issues Skelly et al 2022 This discussion focuses on preventable falls within healthcare environments speci cally analyzing a case of an 86 year old patient named Michelle who experienced a fall in the Cardiovascular CV step down unit at Miami Valley Hospital during her postoperative recovery Case Study Preventable Falls in Healthcare Settings Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us contact OnlineClassAssignment com Website OnlineClassAssignment com For Free MSN Sample OnlineClassAssignment com free Sample Identifying Missed Steps Protocol Deviations and Knowledge Gaps Research highlights that hospitalized patients face an increased risk of falls as indicated by various risk assessment tools LeLaurin Shorr 2019 Those recovering from cardiovascular events and elderly patients particularly those post surgery are notably vulnerable to falls Dworsky et al 2021 Manemann et al 2018 In Michelle s case the primary nurse Kellyn failed to acknowledge the patient s fall risk score indicating a knowledge gap and a failure to prioritize safety Furthermore the nurse did not fully comprehend the patient s environment and preventive measures for falls It is imperative for nurse managers to establish and enforce policies that prevent deviations from protocols and uphold safety standards The Morse Fall Scale MFS is a widely adopted tool for assessing fall risk classifying patients into low medium and high risk categories based on speci c criteria Kim et al 2021 Enhancing healthcare providers skills in risk assessment is crucial for ensuring patient safety Key areas that require investigation include understanding why Nurse Kellyn did not monitor her patients adequately the involvement of other healthcare providers family engagement and whether the patient was informed about fall prevention strategies Addressing these factors is essential for a comprehensive analysis of the incident s underlying causes OnlineClassAssignment com Stakeholders including patients family members nurses and hospital administrators are integral to the healthcare process Adverse events can have serious repercussions for patients and their families and may result in legal consequences for hospital management These outcomes can damage the hospital s reputation and diminish the quality of care provided Baris Seren Intepeler 2018 Effective collaboration among stakeholders is crucial for maintaining high standards in healthcare All involved parties share responsibility for medical errors and must work together to prevent adverse events Healthcare facilities such as Miami Valley Hospital need to implement strategies to minimize and manage these events Quality Improvement Actions and Technological Solutions Implications for Stakeholders Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us contact OnlineClassAssignment com Website OnlineClassAssignment com For Free MSN Sample OnlineClassAssignment com free Sample To reduce falls several strategies and quality improvement actions are recommended These include identifying patients at risk using alarms providing sitters educating patients modifying the environment judicious use of restraints and supplying non slip socks LeLaurin Shorr 2019 Technological solutions such as Portable Video Monitoring PVM during nighttime have shown potential in decreasing falls Woltsche et al 2022 Conclusion Outline for a Quality Improvement Initiative Evaluation metrics for these strategies and technologies should include comparisons of fall rates before and after implementation effectiveness of patient education cost effectiveness ease of use for nurses and ongoing nurse training Morat et al 2023 Montero Odasso et al 2021 The Lean Six Sigma LSS methodology can improve process e ciency in healthcare settings The DMAIC approach De ne Measure Analyze Improve Control provides a structured framework for these improvement efforts Tufail et al 2022 Quality improvement strategies may involve team restructuring staff education regular audits and feedback and patient education Tricco et al 2019 These strategies should be consistently monitored and sustained to ensure long term effectiveness OnlineClassAssignment com Ensuring patient safety and enhancing the quality of healthcare are essential objectives Quality improvement initiatives that incorporate assessment tools staff and patient education and technological interventions are crucial 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 overall healthcare quality Do you need Help to complete your Capella Uni MSN FlexPath Class in 1 Billing Email Us contact OnlineClassAssignment com Website OnlineClassAssignment com For Free MSN Sample OnlineClassAssignment 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 Classi cation 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