Write a comprehensive analysis (5-7 pages) of an adverse event or near miss from your nursing experience. Integrate research and data on the event to propose a quality improvement (QI) initiative to your current organization. Health care organizations strive to create a culture of safety. Despite technological advances, quality care initiatives, oversight, ongoing education and training, legislation, and regulations, medical errors continue to be made. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. Many errors are attributable to ineffective interprofessional communication. This assessment’s goal is to address a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities with a quality improvement initiative to prevent future incidents. Demonstration of Proficiency By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria: Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Analyze the missed steps or protocol deviations related to an adverse event or near miss. Analyze the implications of the adverse event or near miss for all stakeholders. Outline a quality improvement initiative to prevent a similar adverse event or near miss. Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures. Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement. Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care. Communicate analysis and proposed initiative in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling. Integrate relevant sources to support arguments, correctly formatting citations and references using APA style. Instructions For this assessment, you will prepare a comprehensive analysis on an adverse event or near miss that you or a peer experienced during your professional nursing career. You will integrate research and data on the event and use this information as the basis for a quality improvement (QI) initiative proposal in your current organization. The following points correspond to the grading criteria in the scoring guide. The subbullets under each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your adverse event or near-miss analysis addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels relating to each grading criterion. Analyze the missed steps or protocol deviations related to an adverse event or near miss. Describe how the event resulted from a patient’s medical management rather than from the underlying condition. Identify and evaluate the missed steps or protocol deviations leading to the event. Explain the extent to which the incident was preventable. Research the impact of the same type of adverse event or near miss in other facilities. Analyze the implications of the adverse event or near miss for all stakeholders. Evaluate the short- and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze each stakeholder’s contribution to the event. Analyze the interprofessional team’s responsibilities and actions. Explain what measures each interprofessional team member should have taken to create a culture of safety. Describe any change to process or protocol implemented after the incident. Evaluate quality improvement tec…
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