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Health care organizations strive for a culture of safety. Yet despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation and regulations, medical errors continue to occur. 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.
Historically, medical errors were reported and analyzed in hindsight. Today, quality improvement initiatives attempt to be proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by new technologies and reporting metrics, adverse events and near misses can provide insight into potential ways to improve care delivery and ensure patient safety.
For clarification, the National Quality Forum (2009) defines the following:
Adverse event: An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.
Near miss: An event or a situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention.
The goal of this assignment is to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a QI initiative to prevent future incidents.
Research the impact of the same type of adverse event or near miss in other facilities. Evaluate how it was managed, who was involved, and how it was resolved. How have other institutions integrated solutions that prevent these types of events?
Examine what kind of interprofessional communication could have prevented this event.
Integrate research and data on the event, and use it as a basis to propose a QI initiative in your current organization.
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.
Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.
Outline a quality improvement initiative to prevent a future adverse event or near miss.
Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
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 a seminal work) of scholarly or professional evidence to support your evaluation, recommendations, and plans.
Health care organizations strive for a culture of safety. Yet despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation and regulations, medical errors continue to occur. Some are small and easily remedied with the patient unaware of the infraction.