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

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Assessment 1: Adverse Event or Near-Miss Analysis
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Student Name
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Capella University
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Prof Name
Feb 26, 2024

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Adverse Event or Near-Miss Incident Analysis
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Adverse events (AEs) or near-miss incidents unfortunately occur frequently in
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healthcare settings. Adverse events refer to undesirable outcomes resulting from
preventable actions or medical interventions compromising patient safety and well-being
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(Schwendimann et al., 2018). Conversely, near-miss events are situations that could
have caused harm or injury to patients if they had occurred (Yang & Liu, 2021).
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Research conducted across 27 countries on six continents reveals that approximately

10% of hospitalized patients experience adverse events, with 7.3% being
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life-threatening and a significant proportion being preventable (Schwendimann et al.,

2018). These events lead to adverse outcomes for patients, contributing to over
100,000 deaths due to care-related issues (Skelly et al., 2022).
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Analysis of the Incident: Preventable Falls in Healthcare Settings
This analysis focuses on preventable falls in healthcare settings, particularly highlighting

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a case involving an 86-year-old patient named Michelle, who experienced a fall in the
Cardiovascular (CV) step-down unit at Miami Valley Hospital in the United States during
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her postoperative recovery.

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Identifying Missed Steps, Protocol Deviations, and Knowledge Gaps
Studies indicate that regardless of their condition, hospitalized patients are at risk of
falls as per risk assessment tools (LeLaurin & Shorr, 2019). Patients who have recently
experienced cardiovascular incidents and the elderly, especially those who have
undergone surgery, are particularly vulnerable to falls (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 failure to prioritize tasks. Additionally,
the nurse needed to gain awareness of the patient's environment and measures for fall
prevention. Nurse managers must establish policies to prevent protocol deviations and
uphold patient safety standards.
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The Morse Fall Scale (MFS), a widely accepted tool for fall risk assessment,
categorizes patients into low, medium, and high-risk levels based on specific criteria
(Kim et al., 2021). Healthcare providers must enhance their risk assessment skills to
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ensure patient safety.
Key missing information includes why Nurse Kellyn needed to adequately monitor her
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patients, the actions of other healthcare providers, family involvement, and whether the
patient was informed about fall risk prevention measures. Addressing these questions is
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essential for a more comprehensive analysis of the incident's root causes.
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Implications for Stakeholders
Stakeholders, including patients, family members, nurses, and hospital administration,

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play vital roles in healthcare. Adverse events negatively affect patients and their
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families, while legal ramifications create a challenging environment for hospital

administration. Negative consequences may include a tarnished hospital reputation and
compromised healthcare quality (Baris & Seren Intepeler, 2018).
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Effective collaboration among stakeholders is paramount for ensuring quality

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healthcare. All stakeholders bear responsibility for errors in medical practices and must
work together to prevent adverse events. Healthcare organizations, such as Miami
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Valley Hospital, must implement measures to minimize adverse events and mitigate
their impacts.
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Quality Improvement Actions and Technologies

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Various strategies and quality improvement actions are recommended for fall
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prevention, such as identifying at-risk patients, implementing alarms, providing sitters,

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offering patient education, making environmental modifications, using restraints
cautiously, and providing non-slip socks (LeLaurin & Shorr, 2019). Technological
interventions like Portable Video Monitoring (PVM) during nighttime have shown
promise in reducing falls (Woltsche et al., 2022).
Evaluation metrics for these actions and technologies include comparing fall rates
before and after implementation, assessing patient education effectiveness, considering
cost-effectiveness, evaluating ease of use for nurses, and providing ongoing nurse
education (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 efficiency of processes in
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healthcare settings. The DMAIC approach (Define, Measure, Analyze, Improve, Control)
provides a structured framework for improvement efforts (Tufail et al., 2022). Quality
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improvement strategies may involve team restructuring, staff education, regular audits
and feedback, and patient education (Tricco et al., 2019). These strategies should be
continuously monitored and sustained for long-term effectiveness.
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Conclusion
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Ensuring patient safety and improving healthcare quality are paramount goals in
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healthcare. Quality improvement initiatives, encompassing assessment tools, staff and
patient education, and technological interventions, are crucial for addressing the root
causes of adverse events. Effective collaboration among stakeholders and
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implementing these measures will enhance patient safety and healthcare quality.
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References
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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
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Classification of Functioning, disability, and Health. Journal of Clinical Nursing, 28(3-4),

615–628. https://doi.org/10.1111/jocn.14656
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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
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perioperative outcomes after elective inpatient surgery. Journal of Surgical Research,

259, 192–199. https://doi.org/10.1016/j.jss.2020.11.011
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Call Us Now (612) 234-7670
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
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
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).
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https://doi.org/10.1161/circoutcomes.117.004199
Morat, T., Snyders, M., Kroeber, P., De Luca, A., Squeri, V., Hochheim, M., Ramm, P.,
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Breitkopf, A., Hollmann, M., & Zijlstra, W. (2023). Evaluation of a novel
technology-supported fall prevention intervention – study protocol of a multi-center
randomized controlled trial in older adults at increased risk of falls. BMC Geriatrics,
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23(1). https://
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doi.org/10.1186/s12877-023-03810-8
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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
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Velde, N., Verghese, J., & Masud, T. (2021). Evaluation of clinical practice guidelines on
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fall prevention and management for older adults. JAMA Network Open, 4(12),
e2138911. https://doi.org/10.1001/jamanetworkopen.2021.38911
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Schwendimann, R., Blatter, C., Dhaini, S., Simon, M., & Ausserhofer, D. (2018). The
occurrence, types, consequences, and preventability of in-hospital adverse events – a
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scoping review. BMC Health Services Research, 18(1).

https://doi.org/10.1186/s12913-018-3335-z
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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
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of Punjab and optimizing CT scan patient load in Urban City Hospitals. AIMS Public
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Health, 9(2), 440–457. https://doi.org/10.3934/publichealth.2022030

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Tricco, A. C., Thomas, S. M., Veronika, 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
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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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
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Assessment 1: Adverse Event or Near-Miss Analysis

Feb 26, 2024

Research conducted across 27 countries on six continents reveals that approximately

life-threatening and a significant proportion being preventable (Schwendimann et al.,

Analysis of the Incident: Preventable Falls in Healthcare Settings

This analysis focuses on preventable falls in healthcare settings, particularly highlighting

her postoperative recovery.

Stakeholders, including patients, family members, nurses, and hospital administration,

families, while legal ramifications create a challenging environment for hospital

Effective collaboration among stakeholders is paramount for ensuring quality

Quality Improvement Actions and Technologies

prevention, such as identifying at-risk patients, implementing alarms, providing sitters,

Outline for a Quality Improvement Initiative

Classification of Functioning, disability, and Health. Journal of Clinical Nursing, 28(3-4),

perioperative outcomes after elective inpatient surgery. Journal of Surgical Research,

scoping review. BMC Health Services Research, 18(1).

Health, 9(2), 440–457. https://doi.org/10.3934/publichealth.2022030

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