NURS-FPX6016 Assessment 1: Adverse Event or Near-Miss Analysis

CLASS:

NURS-FPX6016: Assessment 1 – 3

NURS-FPX6016 Assessment 1: Adverse Event or Near-Miss Analysis

Instructions

Prepare a comprehensive analysis of an adverse event or a near miss from your professional nursing experience that you or a peer experienced. Provide an analysis of the impact of the same type of adverse event or near miss in other facilities. How was it managed, who was involved, and how was it resolved? Be sure to:

• Analyze the implications of the adverse event or near miss for all stakeholders.
• Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.
• Evaluate QI actions or technologies related to the event that are required to reduce risk and increase patient safety.
• Evaluate how other institutions integrated solutions to prevent these types of events.
• Incorporate relevant metrics of the adverse event or near miss to support need for improvement.
• Outline a QI initiative to prevent a future adverse event or near miss.
• Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Be sure your analysis addresses all of the above points. You may also want to read the Adverse Event or Near Miss Analysis Scoring Guide to better understand the performance levels that relate to each criterion.

SOLUTION

Introduction

In healthcare, patient safety remains a critical priority. Despite advancements in technology, quality care initiatives, and ongoing education, medical errors and adverse events continue to challenge the system, causing harm to patients and stakeholders. This analysis focuses on a specific adverse event—a medication error involving the administration of the wrong dose of insulin to a patient—that occurred in a professional nursing context. The aim is to analyze the implications, investigate the root causes, and propose a quality improvement (QI) initiative to prevent future occurrences. Through this effort, we seek to enhance patient safety, improve outcomes, and uphold the organizational commitment to delivering high-quality care.

Analysis of the Adverse Event

The adverse event under consideration involved administering a double dose of insulin to a hospitalized patient with type 2 diabetes. The error occurred due to a miscommunication during a nursing handoff and a………….…………………………purchase solution at $10