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

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

    Student Name

    Capella University

    NURS-FPX 6016 Quality Improvement of Inter-professional Care

    Prof. Name


    Analysis of Adverse Events and Near-Miss Incidents

    In healthcare settings, adverse events (AEs) or near-miss incidents are prevalent. Adverse events are defined as undesirable outcomes resulting from preventable actions or medical interventions that compromise patient safety and well-being (Schwendimann et al., 2018). Near-miss events, on the other hand, are incidents that, if they had occurred, could have caused harm or injury to the consumers (Yang & Liu, 2021). A global study involving 25 studies across 27 countries and six continents revealed that approximately 10% of hospital patients experience adverse events, with 7.3% of these events being life-threatening (Schwendimann et al., 2018).

    Moreover, 34-83% of these events were described as preventable (Schwendimann et al., 2018). Additional research suggests that over 250,000 patients face adversities during treatment, leading to more than 100,000 patient deaths attributed to the care they receive (Skelly et al., 2022). Preventable adverse events encompass nosocomial diseases, patient falls, medication errors, and surgery-related complications. This analysis focuses on preventable falls in healthcare settings, exploring strategies based on a case in the Cardiovascular (CV) step-down unit at Miami Valley Hospital in the United States.

    The case involves Michelle, an 86-year-old female patient who underwent elective bypass grafting surgery. While staying in the CV step-down unit, she experienced a fall due to the absence of side rails, an elevated bed level, and unlocked bed wheels. The incident prompted legal actions against the nurse and the hospital, emphasizing the need for adverse event analysis to enhance patient safety and quality improvement.

    Analysis of Missed Steps, Protocol Deviations, and Knowledge Gaps

    Hospitalized patients, regardless of their disease process, are considered at risk of falls, especially those with recent cardiovascular incidences and the geriatric population post-surgery (LeLaurin & Shorr, 2019; Manemann et al., 2018). In Michelle’s case, the frontline nurse missed identifying the patient’s fall risk score, showcasing a knowledge gap in assessing fall risk. The nurse also lacked awareness of the patient’s environment and fall prevention measures.

    To address these issues, nurse managers should develop policies to prevent protocol deviations and ensure patient safety. Utilizing established fall risk assessment tools, such as the Morse Fall Scale (MFS), can categorize patients into low, medium, and high-risk levels, aiding healthcare providers in enhancing their risk assessment skills (Kim et al., 2021).

    However, questions remain about why nurse Kellyn did not monitor her patients adequately, the roles of other healthcare providers, the family’s inaction, and whether the patient was informed about fall risk prevention measures. Answers to these questions could provide a more comprehensive analysis of the root causes of the event.

    Analysis of Implications for Stakeholders

    Stakeholders, including patients, families, healthcare providers, and hospital administration, play crucial roles in healthcare quality. Negative impacts from adverse events, such as legal actions and reputational decline, affect patients, families, and healthcare providers (Baris & Seren Intepeler, 2018). Effective collaboration among stakeholders is vital for quality healthcare, and all stakeholders share responsibility for errors in medical practices.

    To mitigate these negative impacts, healthcare organizations should establish measures, including effective communication, education, and policies, to minimize adverse events and enhance patient safety (López-Soto et al., 2021).

    Quality Improvement Actions and Technologies

    Various fall prevention interventions, including risk identification, alarms, sitters, patient education, and environmental modifications, can be implemented (LeLaurin & Shorr, 2019). Additionally, technologies such as portable video monitoring (PVM) have proven effective in reducing fall rates, showcasing the potential for technology-supported fall prevention strategies (Woltsche et al., 2022).

    To evaluate these actions, metrics such as falls before and after implementation, patient education, cost-effectiveness, ease of use for nurses, and nurse education should be considered (Morat et al., 2023; Montero-Odasso et al., 2021).

    Outline for a Quality Improvement Initiative

    Implementing Lean Six Sigma (LSS) methodology, specifically the DMAIC approach (Define, Measure, Analyze, Improve, Control), can enhance the capability and efficacy of processes in healthcare settings (Rathi et al., 2022; Tufail et al., 2022). Quality improvement strategies, including team changes, staff education, frequent audits, and patient education, are essential components of a comprehensive initiative (Tricco et al., 2019).


    Ensuring patient safety and quality improvement in healthcare requires a balanced approach. By implementing quality improvement initiatives, utilizing assessment tools, educating staff and patients, and incorporating technologies like portable video monitoring, healthcare organizations can address the root causes of adverse events. Effective collaboration among stakeholders is crucial for successful implementation, ultimately improving patient safety and healthcare quality.


    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 Classification of functioning, disability and health. Journal of Clinical Nursing, 28(3-4), 615–628.

    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 after elective inpatient surgery. Journal of Surgical Research, 259, 192–199.

    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.

    Laird, Y., Manner, J., Baldwin, L., Hunter, R., McAteer, J., Rodgers, S., Williamson, C., & Jepson, R. (2020). Stakeholders’ experiences of the Public Health Research Process: Time to change the system? Health Research Policy and Systems, 18(1).

    LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients. Clinics in Geriatric Medicine, 35(2), 273–283.

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

    López-Soto, P. J., López-Carrasco, J. de, Fabbian, F., Miñarro-Del Moral, R. M., Segura-Ruiz, R., Hidalgo-Lopezosa, P., Manfredini, R., & Rodríguez-Borrego, M. A. (2021). Chronoprevention in Hospital Falls of older people: Protocol for a mixed-method study. BMC Nursing, 20(1).

    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).

    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 Velde, N., Verghese, J., & Masud, T. (2021). Evaluation of clinical practice guidelines on fall prevention and management for older adults. JAMA Network Open, 4(12), e2138911.

    Morat, T., Snyders, M., Kroeber, P., De Luca, A., Squeri, V., Hochheim, M., Ramm, P., Breitkopf, A., Hollmann, M., & Zijlstra, W. (2023). Evaluation of a novel technology-supported fall prevention intervention – study protocol of a multi-centre randomised controlled trial in older adults at increased risk of falls. BMC Geriatrics, 23(1).

    Rathi, R., Vakharia, A., & Shadab, M. (2022). Lean six sigma in the healthcare sector: A Systematic Literature Review. Materials Today: Proceedings, 50, 773–781.

    Skelly, C. L., Cassagnol, M., & Munakomi, S. (2022). Adverse events. In StatPearls. StatPearls Publishing.

    Schwendimann, R., Blatter, C., Dhaini, S., Simon, M., & Ausserhofer, D. (2018). The occurrence, types, consequences and preventability of in-hospital adverse events – a scoping review. BMC Health Services Research, 18(1).

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

    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 of Punjab and optimizing CT scan patient load in Urban City Hospitals. AIMS Public Health, 9(2), 440–457.

    Tricco, A. C., Thomas, S. M., Veroniki, 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.

    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.

    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.