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

Student Name

Capella University

NURS-FPX 6016 Quality Improvement of Interprofessional Care

Prof. Name

Date

Adverse Event or Near Miss Analysis

Adverse events and near misses are slightly different terms, yet both impact patient safety and quality of care. An adverse event is a scenario that results in unintentional harm to a patient due to either an omitted act or an act of commission in patient care treatments and has nothing to do with the patient’s underlying health condition. A near-miss event can potentially cause patient harm but does not produce any adverse event due to timely intervention (Curtis et al., 2021).

In this assessment, an adverse event analysis will be conducted for a patient who experienced a fall and encountered a hip fracture. The incident occurred at Tampa General Hospital, negatively impacting the patient and relevant stakeholders. Additionally, the paper will discuss the missed steps and deviations from standard guidelines due to which the incident occurred. Lastly, the QI initiative and technologies will be briefed to prevent the incident in the future.

Comprehensive Analysis of Adverse Event

One fine evening at Tampa General Hospital, an elderly patient named George was admitted for pneumonia. Due to his weakened state, she required assistance with mobility. Despite the nurse’s diligent efforts to ensure the patient’s safety, an adverse event of a patient fall occurred. The patient complained of feeling warm, and the nurse opened the window to allow fresh air into the room. However, the sudden temperature change caused George to feel lightheaded when he stood up to go to the bathroom. The patient required assistance to hold on to walk steadily, and the nurse forgot to provide a mobility aid for the patient.

The patient tripped on the floor due to an unsteady state of mind. The fall resulted in a hip fracture, causing significant pain and immobilizing him further. The nurse on duty heard the massive noise of a thud, which forced her to rush to the patient’s bed, and the medical team was called immediately to perform the hip surgery right away and alleviate the patient’s pain.

Implications of Adverse Event for Relevant Stakeholders

Patient falls are when patients unintentionally descend to the ground or lower level, often resulting in injury. Patient falls are considered adverse events in healthcare settings as they can lead to physical harm, emotional distress, prolonged hospital stays, and even fatalities. Consequently, patient falls impact patient safety due to fractures and mobility impairments, as one study states that 25% of patient falls at hospitals result in fractures and cause injuries to patients (Heng et al., 2020).  Moreover, patient falls indicate a breakdown in the care process, displaying a poor quality of care delivered in healthcare settings.

In George’s case, the adverse event of the fall resulted in various implications for specific stakeholders, including the patient himself, family members, nurses, and the hospital. The patient faced significant physical pain due to a hip fracture and impaired mobility for a longer duration. Moreover, this caused the need for additional treatments, emotional distress, and prolonged hospitalization (Beckett et al., 2021). The patient’s quality of life was severely impacted due to extensive medical interventions and rehabilitation. The family members, including George’s son and wife, experienced emotional turmoil, seeing their loved one go through physical and mental trauma due to a fall.

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

They were disappointed by hospital management and providers who could not deliver quality patient care without their family members. The nurse in charge of the ward and patient faced professional distress and litigation followed by the patient fall incident (Beckett et al., 2021). Moreover, the nursing department was under enhanced scrutiny, workload, and pressure to address the deficiencies in patient safety protocols and prevent similar incidents in the future. Lastly, the organization encountered backlash from patients’ family members and surrounding patients, resulting in a decline in reputation. Moreover, the legal liabilities and financial repercussions also resulted from the patient’s fall incidence. The hospital administration conducted an internal investigation to understand the incident further and be proactive in preventing such incidents in the future (Liston et al., 2021). 

This analysis is based on several assumptions, such as:

• A patient’s health is the foremost priority for healthcare professionals, including nurses, and requires timely interventions to facilitate his needs.
• Family members trust healthcare professionals to prioritize patient safety and provide transparent communication regarding the patient’s condition and treatment.
• Healthcare professionals, including nurses, are supposed to deliver high-quality care treatments, ensuring patient safety, which fulfills their ethical duties (Burgener, 2020).
• Healthcare organizations aim to enhance patient safety and quality improvement initiatives and must have established protocols and guidelines for fall prevention (WHO, 2021).

Sequences of Events, Missed Steps/ Protocol Deviations

The hospital administration conducted a thorough root-cause analysis to better comprehend the cause of George’s patient fall. The patient being treated for pneumonia felt warm and asked the nurse if she could open the window for fresh air. The nurse opened the window, which caused a sudden temperature change. After that, she went to her staff room and forgot to shut the window after some time. Moreover, the patient felt lightheaded due to the temperature change and needed to go to the bathroom. The patient could not find any nurse in the ward, and his family was also home from an emergency.

The patient looked for a mobility aid and found none. As a result, the patient fell awkwardly on his left side, which led to a hip fracture. The nurse heard the fall sound and returned to a patient lying on the floor. The missed steps included failure to evaluate the patient’s mobility and risk of falling, and lack of environmental safety measures such as closing windows timely and providing mobility aids for patients prone to collapse (Liston et al., 2021). Moreover, the suboptimal monitoring of the patient’s vital signs and response to medication also contributed to feelings of lightheadedness, which caused a fall event.

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

The fall prevention protocols, including prompt response to patient requests for assistance, were not adequately implemented, which showed inadequate training and adherence to these guidelines among healthcare staff. There was also a need for better communication channels among nurses and patients to promote quick responses to urgent health needs (Turner et al., 2020).  

While the analysis provided the root causes of the event, there are still some knowledge gaps and areas of uncertainties that require further information for better analysis. Additional information is needed to understand whether the patient’s medical history could provide insight into their risk profile. Why did the nurse not return to ensure the patient’s environment was safe and conducive to his health? What were the reasons for the communication gap between patients and nursing staff? If the patient required mobility aids, why did hospital management not know the patient’s needs beforehand? These areas require additional information to improve the analysis (Turner et al., 2020).

Quality Improvement Actions and Technologies

Specific quality improvement actions and technologies are evaluated that can be implemented within the healthcare system to reduce the risks of patient falls. These include implementing a comprehensive fall risk assessment protocol, environmental modifications, improved communication protocols and channels, and technological solutions. As the incident occurred due to a lack of risk evaluation for the patient, a comprehensive fall risk assessment protocol must be established and enacted (Odasso et al., 2022). The protocol must include ways to assess the patient’s risk of falls and effective interventions based on risk assessment. Additionally, environmental modification should be ensured to make the surroundings conducive to patient safety and health, such as proper lighting, providing mobility aids to vulnerable patients, and clearing pathways and floors (LaHue et al., 2020).

The communication protocols and channels must be established, such as integrating patient call buttons to reduce the frequency of communication delays and the onset of patient falls. Technological advancements, such as bed and patient monitoring alarms, must be integrated to minimize patient falls (Oh-Park et al., 2020). Nurses can also use remote monitoring to analyze the vital signs impacting patient mobility. The effectiveness of the newly implemented technologies and actions can be measured by assessing the criteria such as reduction in fall rates, enhanced patient satisfaction and reduced costs needed for additional treatments for injuries associated with patient falls  (Fehlberg et al., 2020).

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

Other hospital organizations have integrated similar solutions, such as implementing electronic health record systems with in-built systems of fall risk assessment and alerts for high-risk patients (Lindberg et al., 2020). These hospital departments have also conducted regular safety rounds to identify environmental hazards to address promptly and prevent falls. They have also established multidisciplinary fall prevention committees to review incidents and determine areas for improvement to prevent future issues of patient falls (Turner et al., 2020). The hospital metrics relevant to patient falls can be evaluated to assess the care quality needed.

These metrics include the number of patient falls per month or year, the rate of falls per 1000 patient bed days, the proportion of falls resulting in injuries such as fractures, and compliance with fall risk assessment protocols. The hospital data was gathered on the rate of falls per 1000 patient bed days and found to be 8.6 falls/1000 patient bed days, which exceeded the national benchmark for patient falls with a rate of 3.44 falls/1000 patient bed days (Venema et al., 2019). These data indicate the need for improvement in preventing fall rates in hospitals.

Quality Improvement Initiative Outline

The patient fall incident was managed by prompt delivery of care treatments to George, who required hip surgery to fix the fracture and manage pain effectively. The patient was under scrutiny to ensure patient safety. To address patient falls in the future in the Tampa General Hospital, a quality improvement initiative that can be implemented is to develop and practice standardized fall risk evaluation protocols to accurately locate patients with high vulnerability for falls upon admission and throughout their hospital stays (Odasso et al., 2022). For this purpose, multidisciplinary team members comprising nurses, physicians, and quality improvement personnel will collaborate to create a toolkit for fall risk assessment.

This will include guidelines for the standardized evaluation such as fall history, mobility impairment, cognitive status, and medication use. Training and education will be provided to providers to evaluate the fall risk and document the findings in EHR systems. Other QI initiatives include bed alarms, gait belts, environmental modifications, and alarming notifications within EHR systems (LaHue et al., 2020; Oh-Park et al., 2020). These solutions are considered better options as they are convenient for providers to use and are technology-based, showing the conflicting perspectives of researchers.

Conclusion

The Tampa General Hospital faced a patient fall incident due to several missed steps. These included a lack of standardized protocols for fall risk assessment, poorly managed environmental hazards, negligence of nurses, and poor communication channels between nurse and patient. The incident impacted patients and other stakeholders, requiring better performance and implementation of quality actions and technologies. The QI initiative outlined is developing and implementing comprehensive fall risk assessment protocols to prevent future patient fall events.

References

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Burgener, A. M. (2020). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Care Manager, 39(3), 128–132. https://doi.org/10.1097/hcm.0000000000000298 

Curtis, N. J., Dennison, G., Brown, C. S. B., Hewett, P. J., Hanna, G. B., Stevenson, A. R. L., & Francis, N. K. (2021). Clinical evaluation of intraoperative near misses in laparoscopic rectal cancer surgery. Annals of Surgery, 273(4), 778. https://doi.org/10.1097/SLA.0000000000003452 

Fehlberg, E. A., Cook, C. L., Bjarnadottir, R. I., McDaniel, A. M., Shorr, R. I., & Lucero, R. J. (2020). Fall prevention decision making of acute care registered nurses. JONA: The Journal of Nursing Administration, 50(9), 442–448. https://doi.org/10.1097/nna.0000000000000914 

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

Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A.-M., & Morris, M. E. (2020). Hospital falls prevention with patient education: A scoping review. BMC Geriatrics, 20(1), 1–12. https://doi.org/10.1186/s12877-020-01515-w 

LaHue, S. C., James, T. C., Newman, J. C., Esmaili, A. M., Ormseth, C. H., & Ely, E. W. (2020). Collaborative delirium prevention in the age of COVID ‐19. Journal of the American Geriatrics Society, 68(5), 947–949. https://doi.org/10.1111/jgs.16480

Lindberg, D. S., Prosperi, M., Bjarnadottir, R. I., Thomas, J., Crane, M., Chen, Z., Shear, K., Solberg, L. M., Snigurska, U. A., Wu, Y., Xia, Y., & Lucero, R. J. (2020). Identification of important factors in an inpatient fall risk prediction model to improve the quality of care using EHR and electronic administrative data: A machine-learning approach. International Journal of Medical Informatics, 143, 104272. https://doi.org/10.1016/j.ijmedinf.2020.104272  

Liston, M., Genna, G., Maurer, C., Kikidis, D., Gatsios, D., Fotiadis, D., Bamiou, D.-E. ., & Pavlou, M. (2021). Investigating the feasibility and acceptability of the holobalance system compared with standard care in older adults at risk for falls: Study protocol for an assessor blinded pilot randomised controlled study. BMJ Open, 11(2). https://discovery.ucl.ac.uk/id/eprint/10122382/ 

Odasso, M. M., van der Velde, N., Martin, F. C., Petrovic, M., Tan, M. P., Ryg, J., Aguilar-Navarro, S., Alexander, N. B., Becker, C., Blain, H., Bourke, R., Cameron, I. D., Camicioli, R., Clemson, L., Close, J., Delbaere, K., Duan, L., Duque, G., Dyer, S. M., & Freiberger, E. (2022). World guidelines for falls prevention and management for older adults: A global initiative. Age and Ageing, 51(9). https://doi.org/10.1093/ageing/afac205 

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

Oh-Park, M., Doan, T., Dohle, C., Vermiglio-Kohn, V., & Abdou, A. (2020). Technology utilization in fall prevention. American Journal of Physical Medicine & Rehabilitation, 100(1). https://doi.org/10.1097/phm.0000000000001554

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Turner, K., Staggs, V., Potter, C., Cramer, E., Shorr, R., & Mion, L. C. (2020). Fall prevention implementation strategies in use at 60 United States hospitals: A descriptive study. BMJ Quality & Safety, 29(12), bmjqs-2019-010642. https://doi.org/10.1136/bmjqs-2019-010642 

Venema, D. M., Skinner, A. M., Nailon, R., Conley, D., High, R., & Jones, K. J. (2019). Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study. BMC Geriatrics, 19(1). https://doi.org/10.1186/s12877-019-1368-8 

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