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Adverse Event or Near Miss Analysis

Adverse Event or Near Miss Analysis

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Assessment Instructions

PREPARATION

Prepare a comprehensive analysis on an adverse event or near-miss from your professional nursing experience that you or a peer experienced. Integrate research and data on the event and use as a basis to propose a Quality Improvement (QI) initiative in your current organization.

Note: Remember, you can submit all, or a portion of, your draft to Smarthinking for feedback, before you submit the final version of your analysis for this assessment. However, be mindful of the turnaround time for receiving feedback, if you plan on using this free service.

The numbered points below correspond to grading criteria in the scoring guide. The bullets below 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 that relate to each grading criterion.

  1. 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 that led to the event.
    • Discuss the extent to which the incident was preventable.
    • Research the impact of the same type of adverse event or near miss in other facilities.
  2. Analyze the implications of the adverse event or near miss for all stakeholders.
    • Evaluate both short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze how it was managed and who was involved.
    • Analyze the responsibilities and actions of the interprofessional team. Explain what measures should have been taken and identify the responsible parties or roles.
    • Describe any change to process or protocol implemented after the incident.
  3. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
    • Analyze the quality improvement technologies that were put in place to increase patient safety and prevent a repeat of similar events.
    • Determine whether the technologies are being utilized appropriately.
    • Explore how other institutions integrated solutions to prevent these types of events.
  4. Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.
    • Identify the salient data that is associated with the adverse event or near miss that is generated from the facility’s dashboard. (By dashboard, we mean the data that is generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management.)
    • Analyze what the relevant metrics show.
    • Explain research or data related to the adverse event or near miss that is available outside of your institution. Compare internal data to external data.
  5. Outline a quality improvement initiative to prevent a future adverse event or near miss.
    • Explain how the process or protocol is now managed and monitored in your facility.
    • Evaluate how other institutions addressed similar incidents or events.
    • Analyze QI initiatives developed to prevent similar incidents, and explain why they are successful. Provide evidence of their success.
    • Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.
  6. Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
  7. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

SUBMISSION REQUIREMENTS

  • Length of submission: A minimum of five but no more than seven double-spaced, typed pages.
  • Number of references: Cite a minimum of three sources (no older than seven years, unless seminal work) of scholarly or professional evidence that support your evaluation, recommendations, and plans.
  • APA formatting: Resources and citations are formatted according to current APA style and formatting.

SUGGESTED RESOURCES

The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The Nursing Masters (MSN) Research Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you.

Adverse Events and Reporting

These resources explore how cultures focused on safety learn from adverse events.

The following resources explore the benefits and challenges of incident reporting systems.

This resource examines organizational factors that lead to adverse events and near-miss incidents.

Reporting Systems

These resources provide comprehensive event reporting systems data and performance assessment information:

This resource provides examples of adverse events and near-miss incidents:

  • Agency for Healthcare Research and Quality. (2016). WebM&M cases & commentaries. Retrieved from https://psnet.ahrq.gov/webmm
  • adverse_event_o

    The instructional and sample text in this template is informational. After reading the information, please delete it, and use the document as a template for your own paper. To keep the correct format, edit the running head, cover page, headings, and reference list with your own information, and add your own body text. Save this template in a file for future use and information.

     

    The running head is an abbreviated title of the paper. The running head is located at the top of pages of a manuscript or published article to identify the article for readers. The running head should be a maximum of 50 characters, counting letters, punctuation, and spaces between words. The words “Running head” are on the cover page but not on the rest of the document. The running head title is all capital letters. Page 1 begins on the cover page. The entire document should be double-spaced, have 1-inch margins on all sides, and use 12 point Times New Roman font.

     

     

     

     

     

     

    Full Title of Paper

    Learner’s Full Name

    Course Title

    Assignment Title

    Capella University

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    Abstract (As this section is optional, check with your instructor.)

    An abstract is a brief, comprehensive summary of the contents of a paper. It allows readers to quickly review the key elements of a paper without having to read the entire document. This can be helpful for readers who are searching for specific information and may be reviewing many documents. The abstract may be one of the most important paragraphs in a paper because readers often decide if they will read the document based on information in the abstract. An abstract may not be required in some academic papers; however, it can still be an effective method of gaining the reader’s attention. For example, an abstract will not be required for Capella’s first course, PSYC3002. The following sentences serve as an example of what could be composed as an abstract for this paper: The basic elements of APA style will be reviewed, including formatting of an APA style paper, in-text citations, and a reference list. Additional information will address the components of an introduction, how to write effective paragraphs using the MEAL plan, and elements of a summary and conclusion section of a paper.

    APA Style Paper Template: A Resource for Academic Writing

    Please change the titles in this document to fit your paper.

    APA (American Psychological Association) style is most commonly used to cite sources within the social sciences. APA style is used when writing papers in the psychology programs offered at Capella University. This document serves as an APA style template for learners to use when writing their own papers, as well as a resource containing valuable information that can be used when writing academic papers. For more information on APA style, learners can refer to the Publication Manual of the American Psychological Association (American Psychological Association, 2010a).

    The author demonstrates in the first section of this paper how an introduction effectively introduces the reader to the topic of the paper. In APA style, an introduction never gets a heading. For example, this section did not begin with a heading titled “Introduction,” similar to the following section, which is titled “Writing an Effective Introduction.” The following section will explain in greater detail a model that can be used to effectively write an introduction in an academic paper. The remaining sections of the paper will continue to address APA style and effective writing concepts including section headings, organizing information, the MEAL plan, the conclusion, and the reference list.

    Writing an Effective Introduction

    An effective introduction often consists of four main components including (a) the position statement, thesis, or hypothesis, which describes the author’s main position; (b) the purpose, which outlines the objective of the paper; (c) the background, which is general information that is needed to understand the content of the paper; and (d) the approach, which is the process or methodology the author uses to achieve the purpose of the paper. This information will help readers understand what will be discussed in the paper. It can also serve as a tool to grab the reader’s attention. Authors may choose to briefly reference sources that will be identified later on in the paper as in this example (American Psychological Association, 2010a; American Psychological Association, 2010b; Walker, 2008).

    In an introduction, the writer will often present something of interest to capture the reader’s attention and introduce the issue. Adding an obvious statement of purpose helps the reader know what to expect, while helping the writer to focus and stay on task. For example, this paper will address several components necessary to effectively write an academic paper including (a) how to write an introduction, (b) how to write effective paragraphs using the MEAL plan, and (c) how to properly use APA style.

    Level One Section Heading is Centered, Bold, Uppercase and Lowercase

    Using section headings can be an effective method of organizing an academic paper. The section headings should not be confused with the running head, which is a different concept described in the cover page of this document. Section headings are not required according to APA style; however, they can significantly improve the quality of a paper. This is accomplished because section headings help both the reader and the author.

    Level Two Section Heading is Flush Left, Bold, Uppercase and Lowercase

    The heading style recommended by APA consists of five levels (American Psychological Association, 2010a, p. 62). This document contains two levels to demonstrate how headings are structured according to APA style. Immediately before the previous paragraph, a Level 1 heading was used. That section heading describes how a Level 1 heading should be written, which is centered, bold, and using uppercase and lowercase letters. For another example, see the section heading “Writing an Effective Introduction” on page 3 of this document. The heading is centered, bold, and uses uppercase and lowercase letters (compared to all uppercase in the running head at the top of each page). If used properly, section headings can significantly contribute to the quality of a paper by helping the reader who wants to understand the information in the document, and the author who desires to effectively describe the information in the document.

    Section Headings Help the Reader

    Section headings serve multiple purposes including (a) helping readers understand what is being addressed in each section, (b) breaking up text to help readers maintain an interest in the paper, and (c) helping readers choose what they want to read. For example, if the reader of this document wants to learn more about writing an effective introduction, the previous section heading clearly states that is where information can be found. When subtopics are needed to explain concepts in greater detail, different levels of headings are used according to APA style.

    Section Headings Help the Author

    Section headings do not only help the reader, they help the author organize the document during the writing process. Section headings can be used to arrange topics in a logical order, and they can help an author manage the length of the paper. In addition to an effective introduction and the use of section headings, each paragraph of an academic paper can be written in a manner that helps the reader stay engaged. Capella University promotes the use of the MEAL plan to serve this purpose.

    The MEAL Plan

    The MEAL plan is a model used by Capella University to help learners effectively compose academic discussions and papers. Each component of the MEAL plan is critical to writing an effective paragraph. The acronym MEAL is based on four components of a paragraph (M = Main point, E = Evidence or Example, A = Analysis, and L = Link). The following section includes a detailed description and examples of each component of the MEAL plan.

    When writing the content sections of an academic paper (as opposed to the introduction or conclusion sections), the MEAL plan can be an effective model for designing each paragraph. A paragraph begins with a description of the main point, which is represented by the letter “M” of the MEAL plan. For example, the first sentence of this paragraph clearly states the main point is a discussion of the MEAL plan. Once the main point has been made, evidence and examples can be provided.Adverse Event or Near Miss Analysis

    The second component of a paragraph contains evidence or examples, which is represented by the letter “E” in the MEAL plan. An example of this component of the MEAL plan is actually (and ironically) this sentence, which provides an example of an example. Evidence can be in the form of expert opinions from research. For example, evidence shows that plagiarism can occur even when it is not intended if sources are not properly cited (Marsh, Landau, & Hicks, 1997; Walker, 2008). The previous sentence provides evidence supporting why evidence is used in a paragraph.

    Analysis, which is represented by the letter “A” of the MEAL plan, should be based on the author’s interpretation of the evidence. An effective analysis might include a discussion of the strengths and weaknesses of the arguments, as well as the author’s interpretations of the evidence and examples. If a quote is used, the author will likely provide an analysis of the quote and the specific point it makes for the author’s position. Without an analysis, the reader might not understand why the author discussed the information that the reader just read. For example, the previous sentence was an analysis by the author of why an analysis is performed when writing paragraphs in academic papers.

    Even with the first three elements of the MEAL plan, it would not be complete without the final component. The letter “L” of the MEAL plan refers to information that “links” the current and the subsequent paragraphs. The link helps the reader understand what will be discussed in the next paragraph. It summarizes the author’s reasoning and shows how the paragraph fits together and leads (that is, links) into the next section of the paper. For example, this sentence might explain that once the MEAL plan has been effectively used when writing the body of an academic paper, the final section is the summary and conclusion section.Adverse Event or Near Miss Analysis

    Summary and Conclusion

    A summary and conclusion section, which can also be the discussion section of an APA style paper, is the final opportunity for the author to make a lasting impression on the reader. The author can begin by restating opinions or positions and summarizing the most important points that have been presented in the paper. For example, this paper was written to demonstrate to readers how to effectively use APA style when writing academic papers. Various components of an APA style paper that were discussed or displayed in the form of examples include a running head, title page, introduction section, levels of section headings and their use, in-text citations, the MEAL plan, a conclusion, and the reference list.

     

    References

    American Psychological Association. (2010a). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.Adverse Event or Near Miss Analysis

    American Psychological Association. (2010b). Ethical principles of psychologists and code of conduct. Washington, DC: Author. Retrieved from http://www.apa.org/ethics/code/index.aspx

    Marsh, R. L., Landau, J. D., & Hicks, J. L. (1997). Contributions of inadequate source

    monitoring to unconscious plagiarism during idea generation. Journal of Experimental       Psychology: Learning, Memory, and Cognition, 23(4), 886–897. doi: 10.1037/0278-       7393.23.4.886

    Walker, A. L. (2008). Preventing unintentional plagiarism: A method for strengthening

    paraphrasing skills. Journal of Instructional Psychology, 35(4), 387–395. Retrieved from             http://search.proquest.com/docview/213904438?accountid=27965

    Always begin a reference list on a new page. Use a hanging indent after the first line of each reference. The reference list is in alphabetical order by first author’s last name. A reference list only contains sources that are cited in the body of the paper, and all sources cited in the body of the paper must be contained in the reference list.Adverse Event or Near Miss Analysis

     

    The reference list above contains an example of how to cite a source when two documents are written in the same year by the same author. The year is also displayed using this method for the corresponding in-text citations as in the next sentence. The author of the first citation (American Psychological Association, 2010a) is also the publisher, therefore, the word “Author” is used in place of the publisher’s name.Adverse Event or Near Miss Analysis

     

    When a digital object identifier (DOI) is available for a journal article, it should be placed at the end of the citation. If a DOI is not available, a uniform resource locator (URL) should be used. The Marsh, Landau, and Hicks (1997) reference is an example of how to cite a source using a DOI. The Walker (2008) reference is an example of how to cite a source using a URL.