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

Name

Capella university

NURS-FPX 6016 Quality Improvement of Interprofessional Care

Prof. Name

Date

Adverse Event or Near-Miss Analysis

The near-miss incidents and adverse events take a very significant place among healthcare concerns because it is a matter of substantial risk for the safety of patients. Adverse events are undesirable clinical outcomes unrelated to a patient’s underlying condition. Such adverse events include prolongation of hospital stay, causing irreversible damage and requiring critical interventions to prevent death. In contrast, near-miss incidents offer critical learning opportunities by revealing hazards narrowly avoided. Feng et al. (2022) report that annually, hospitals across the globe suffer 134 million adverse events, leading to 2.6 million deaths.

Such dire statistics raise an alarm on how frequent and drastic the situation is, involving instances like patient falls, medication errors, pressure injuries, and hospital-acquired infections. These events are often a result of lapses in the alertness of healthcare professionals. All these can be either prevented or minimized if there is vigilance and adherence to safety measures. This case review will analyze the incident of a particular patient fall at Springfield General Hospital, its outcomes, and practical recommendations for reducing its chances of happening again in the future.

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

Mr. John is a 72-year-old male patient admitted to the hospital after having undergone surgery to replace the right knee. He had a background of Type 2 diabetes mellitus and mild cognitive impairment. Upon admission, his vital signs were stable: BP 130/78, HR 75, and RR 16. After surgery, John was put on pain medication management and encouraged to engage in physical therapy. Nurse Clara, the orthopedic unit head nurse, did the initial fall risk assessment but failed to update it when John complained of dizziness from moving from his bed to his chair. However, Clara still assigned the junior nurse, Mia, to help John ambulate to the bathroom while adhering strictly to the four steps. Mia was attending to another patient and delayed response to the call light.

Meanwhile, John, wanting not to wait, tried to get up alone to the bathroom. He was not steady on his feet and fell and struck his forehead to the floor. The staff attended promptly to John who was found confused and bleeding from a forehead laceration. A CT scan diagnosed John with a mild concussion and extended his hospital stay for five more days. This brought anger from John’s family toward the hospital staff, questioning why such a fall-prevention protocol had not been taken seriously. They filed a complaint against the hospital for negligence.

Analysis of Implications of Adverse Event on Stakeholders

The adverse event of John’s fall at Springfield General Hospital had wide-ranging implications for all stakeholders. In the immediate implication, John suffered from physical injury, delayed recovery, and emotional distress; in the long term, reduced mobility, increased dependency, and the fear of future falls. His family suffered from emotional turmoil, financial strain, and a loss of trust in the healthcare system. The effect of the incident on the interprofessional team was raised stress, scrutiny, and possibly blame: evidence of poor communication and lapses in safety practice. Hospital-level impacts included reputational damage, financial liabilities, and investments in corrective actions. The community’s confidence in the hospital’s safety standards was also affected and might affect health care-seeking behavior.

Assuming that lapses in communication, incomplete patient monitoring, and insufficient adherence to safety protocols were causes of the event. There is also a strong assumption about the robust fall-prevention strategy, including the appropriate time assessment of risk and actual communication among the staff, which may have prevented the incident. Responsibilities include conducting a root cause analysis, providing immediate care, and transparently addressing the event with the patient and family. Preventive measures, including offering necessary training to the staff members, prompt responses to patients’ demands, and documentation improvements, are associated with preventing future incidents (WHO, 2020). This case underlines the interlink between the roles of different stakeholders and their associated requirement of a systemic approach to patient safety.

The sequence of Events, Missed Steps, Protocol Deviation

The adverse event of John’s fall was a result of deviations in the management rather than his condition. The missed critical steps comprised failure to reassess John’s risk for falling after he reported his feeling of dizziness, failure in communication by the nurses during the shift handover, and a delayed response to the call light. These lapses made John attempt to walk unobserved that led him to fall. Root cause analysis showed that there were lapses in the execution of fall-prevention protocols, including documentation and monitoring. The incident also showed lack of proactive measures by providing assistive devices for John or educating him on importance of raising a request for assistance. Had protocols been painstakingly followed, this would have been prevented.

The interprofessional communication failures were central to this incident. Clear and structured handoffs would have communicated the elevated risk of falls with the next shift. Joint work among nurses and the physical therapy group would ensure a safer management of his mobility. The lack of documented real-time expectations and missed chances to address John’s dizziness points out knowledge deficits, specifically not appreciating how transient symptoms like dizziness can progress to an elevated risk of falls. Additional questions remain, such as whether staffing levels or workload contributed to the delayed response and whether the hospital’s fall-prevention training adequately prepared the staff. Addressing these uncertainties could provide deeper insights into preventing such adverse events in the future.

Quality Improvement Actions and Technologies

To avoid adverse events such as a fall by patients, implementation of evidence-based quality improvement actions and technologies will be required. One major action is routine fall risk assessments, using validated tools like the Morse Fall Scale, to identify which patients have specific risks and manage them appropriately (Kim et al., 2021). Staff members should participate in regular training sessions focused on fall-prevention protocols, including clear pathways and proper footwear, and the provision of aids for mobility. Educating patients and families on safety measures is also crucial, engaging them in fall prevention (WHO, 2020).

Another successful strategy is making the healthcare culture of accountability where all members are actively monitoring and reporting safety concerns. Hourly rounding and call lights being accessible are also effective evidence-based approaches at helping mitigate fall risks (Abraham, 2024). All these actions create an environment which showcases patient safety as the priority and minimizes unnecessary falls.

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

Technology plays an important role in preventing falls. Tools like bed alarms and patient-monitoring systems offer proactive alerts. For example, pressure-sensitive bed and chair alarms notify staff when high-risk patients attempt to move unassisted (Wen et al., 2024). Moreover, video monitoring systems can keep track of patients that are prone to falls in real time. Electronic Health Records (EHRs) with decision-support systems can also aid in the prevention of falls by incorporating real-time risk assessment and care planning (Jacobsohn et al., 2022).

For implementation at Springfield General Hospital, these technologies need to be assessed for their effectiveness. Key criteria would include falls before and after implementation, patient satisfaction scores, and the number of times staff responded to alarms (Morris et al., 2022). Monitoring the outcome means constant improvement and ensures the hospital’s safety initiatives work towards national benchmarks that subsequently reduce fall incidents and improve patient care.

Quality Improvement Initiative

To prevent the occurrence of future patient falls at Springfield General Hospital, a quality improvement initiative will be launched using the Plan-Do-Study-Act (PDSA) framework. In this case, the plan is to reduce inpatient falls by 30% over six months through a combination of strategies. These include conducting fall-risk assessments upon admission, daily rounds, and after any changes in a patient’s condition. The staff members will be trained with policies for fall prevention and the existing hospital environment will be altered to make sure there are no potential hazards. The program will also include the consideration for hourly rounding. In contrast, evidence shows that hourly rounding was not effective while other research suggested it was effective and cites effectiveness when paired with other interventions. This difference will be taken into account while implementing the same strategy for Springfield General Hospital (Boot et al., 2023).

The intervention will be conducted in an at-risk unit with bed alarms, EHR-based alerts for at-risk patients, and interdisciplinary rounding, all keeping in mind that every member of staff practices the same safety measure every time. Research on the incidence of falls, patient perceptions, and adherence by the staff are collected. These will then be compared to the pre-initiative data to evaluate the effect of the initiative. Counterpoint, such as alarm fatigue or too much dependence on technology, would also have to be considered.

Even though the alarm system and the EHR alerts are going to help enhance patient safety, some employees may be over-walked by too frequent notification leading to desensitization or missing other alerts (Clodfelter, 2023). Ensuring balance and effectiveness in addressing these concerns will be addressed on the basis of results, such as increasing staff or refining the training program, due to any gaps identified. If the initiative is successful, it will be scaled up to include all departments within the hospital so as to establish the sustainable improvements regarding patient safety while respecting varied opinions about the role of technology, workflows, and staff workload in preventing falls.

Conclusion

In conclusion, the adverse event of John’s fall at Springfield General Hospital highlights critical gaps in communication, adherence to safety protocols, and patient monitoring that led to avoidable harm. By implementing a comprehensive quality improvement initiative using the Plan-Do-Study-Act (PDSA) framework, including fall-risk assessments, staff training, environmental modifications, and technology integration such as bed alarms and EHR alerts, the hospital can significantly reduce fall incidents and improve patient safety. While addressing potential conflicts like alarm fatigue and balancing technology with human oversight, this initiative has the potential to create a safer healthcare environment. Ongoing evaluation and adaptation will be necessary to refine strategies and ensure that all staff members are aligned in their commitment to patient safety, with the goal of scaling these improvements hospital-wide.

References

Abraham, R. (2024). Quality improvement project: Fall prevention among older adults in SNF through staff education and hourly rounding. https://arch.astate.edu/dnp-projects/90/

Boot, M., Allison, J., Maguire, J., & O’Driscoll, G. (2023). QI initiative to reduce the number of inpatient falls in an acute hospital Trust. BMJ Open Quality, 12(1), e002102. https://doi.org/10.1136/bmjoq-2022-002102 

Clodfelter, A. (2023). Improving alarm management practices: Wireless bed exit alerts on medical-surgical units. Translational Projects (Open Access). https://digitalcommons.library.tmc.edu/uthsbmi_dhi_dissertations/6/

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

Feng, T., Zhang, X., Tan, L., Su, Y., & Liu, H. (2022). Near-miss organizational learning in nursing within a tertiary hospital: A mixed methods study. BMC Nursing, 21(1). https://doi.org/10.1186/s12912-022-01071-1  

Jacobsohn, G. C., Leaf, M., Liao, F., Maru, A. P., Engstrom, C. J., Salwei, M. E., Pankratz, G. T., Eastman, A., Carayon, P., Wiegmann, D. A., Galang, J. S., Smith, M. A., Shah, M. N., & Patterson, B. W. (2022). Collaborative design and implementation of a clinical decision support system for automated fall-risk identification and referrals in emergency departments. Healthcare, 10(1), 100598. https://doi.org/10.1016/j.hjdsi.2021.100598 

Kim, Y. J., Choi, K., 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). https://doi.org/10.1111/jocn.16185 

Morris, M., Webster, K., Jones, C., Hill, A.-M., Haines, T., McPhail, S., Kiegaldie, D., Slade, S., Jazayeri, D., Heng, H., Shorr, R., Carey, L., Barker, A., & Cameron, I. (2022). Interventions to reduce falls in hospitals: A systematic review and meta-analysis. Age and Ageing, 51(5), 1–12. https://doi.org/10.1093/ageing/afac077 

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

Wen, M.-H., Chen, P.-Y., Lin, S., Lien, C.-W., Tu, S.-H., Chueh, C.-Y., Wu, Y.-F., Tan, K., Hsu, Y.-L., & Bai, D. (2024). Enhancing patient safety through an integrated internet of things patient care system: Large quasi-experimental study on fall prevention. Journal of Medical Internet Research, 26, e58380–e58380. https://doi.org/10.2196/58380 

World Health Organization. (2020). Patient safety incident reporting and learning systems: technical report and guidance. https://www.who.int/publications/i/item/9789240010338