The goal of this assessment is to allow you 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. It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself in as a health care professional.
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, QI 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 (n.d.) 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.
Adverse Event Analysis 1
Adverse Event Analysis
Jonathan Fisher
School of Nursing and Health Sciences, Capella University
MSN-FP6016: Quality Improvement of Interprofessional Care
February 2021
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Adverse Event Analysis 2
Adverse Event Analysis
The purpose of this paper is to analyze an adverse event that occurred in the intensive care unit at
the hospital where I am currently employed. I will explain the event, analyze potential causes
and detail a quality improvement plan that was decided on to prevent similar events from
occurring in the future.
Description and Analysis of Event
The adverse event I will be analyzing is the development of multiple Hospital-acquired pressure
injuries on a patient who was admitted to the Intensive Care Unit with COVID. The patient was
initially admitted for respiratory distress related to COVID and quickly deteriorated and needed
to be intubated. The patient’s respiratory status continued to decline rapidly and the decision was
made to prone the patient. Due to the large number of COVID patients seen in this unit in the last
year, all the staff were familiar with and comfortable with best practices related to prone
positioning of patients. The patient was placed in the prone position for sixteen hours on 6
consecutive days before there was significant improvement in their respiratory status. One or two
days later it was noted in the electronic medical record that the patient had developed multiple
pressure injuries, including the chin, forehead, upper lip, and chest.
After the pressure injuries were noted, a review of the chart and a discussion with multiple
nurses who had cared for the patient revealed that the patient had not been consistently
repositioned while proned. While hospital protocol recommends repositioning every 2 hours,
including turning the head to the opposite head if possible, this was unable to be accomplished
consistently with this patient. There were multiple reasons in this case, including the patient’s
high acuity (the patient would easily desaturate with even minor movement), the patient’s size
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Adverse Event Analysis 3
and body habitus (the patient was obese and had a large, short neck which made head positioning
very difficult), and insufficient staffing related to the surge of COVID patients (there were shifts
when the nurse caring for this patient also had two other intubated COVID patients).
While the pressure injures were clearly related to prone positioning, they may also be considered
device-related pressure injuries. One was related to either the endotracheal tube or the tube
holder, and another was related to the positioning devices used to support the patient in the prone
position. Device related pressure injuries may at times be harder to prevent, especially in the
sickest patients, and they now account for more than thirty percent of all hospital-acquired
pressure injuries (The Joint Commision, 2018). While the hospital must take responsibility for all
pressure injuries it is a matter of debate as to whether all pressure injuries are truly preventable.
Pittman, (2019) argues that a pressure injury should be considered unavoidable if the patient was
at high risk and all prevention strategies were adequately used. While there were missed
opportunities in this case, the argument could be made that given the patient’s high risk they
were very likely to have pressure injuries related to prone positioning no matter what devices or
interventions were used.
Implications of Event
As hospital-acquired pressure injuries, whether device-related or not, are considered a measure
of the quality of the nursing care provided they are always treated as a significant event. In
addition, any adverse event has the possibility of having a significant effect on the patient and on
the patient’s ongoing care. While most adverse events have primarily short-term effects, up to
fourteen percent can have long-term effects such as permanent disability or eventual death
(Rafter, 2014). In addition to the patient, the family can also be affected by the adverse event,
especially if they perceive the event as having been caused by the healthcare team. While the
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Adverse Event Analysis 4
facility itself will be affected financially, the direct care providers can also be affected either in
the additional care that is required in promoting healing of the pressure injury or in the feelings
of guilt associated with thinking they should have done a better job of preventing the adverse
event.
Quality Improvement Technologies and Techniques
The initial approach to preventing the recurrence of pressure injuries related to prone positioning
was to remind staff to be as diligent as possible with repositioning these patients as much as is
safely possible. As lack of sufficient staffing was recognized as a significant factor, additional
staff from other departments were trained in assisting with repositioning proned patients and an
effort was made to increase the number of available staff on sections of the ICU with proned
patients. There was also discussion on whether the gel and foam positioning devices used were
the optimal available tools. Ultimately it was decided to reach out to vendors for samples of
similar positioning devices and trialing at least one new product. In addition, since on area of
injury was likely related either to the patient's endotracheal tube or the tube holder, a different
tube holder was chosen to be kept in stock on the unit as an option for staff to choose on proned
patients. At this point there was some concern that the different tube holder was likely to be less
secure and could potentially pose a problem in an increased risk of accidental extubation, so the
decision was made to take each patient on a case-by-case basis and let the primary nurse or the
charge nurse decide which device to use for each patient.
Related Metrics
While hospital acquired pressure injuries are a constant area of concern in intensive care units,
our ICU has been making them a point of focus for the last two or more years and has been
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Adverse Event Analysis 5
making significant improvements. On average we have one or two each month and over the last
six months our incidence is 1.3 per 1,000 patient days. This is only slightly above the average for
our entire hospital and is significantly better than other intensive care units across our hospital
system. Our trend over the last several years clearly shows that we are taking the necessary steps
to decrease our hospital acquired pressure injuries. This gives additional weight to the argument
that this particular incident and other recent adverse events are directly related to the current
surge of high acuity COVID patients. There are numerous anecdotal reports of a significant
increase in the incidence of hospital-acquired pressure injuries, as well as other hospital acquired
conditions as a result of the COVID pandemic. Perrilat (2020) mentions this and also opines that
the microvascular changes and thrombosis related to the COVID disease process may also be
increasing the risk of pressure injuries in these patients.
Quality Improvement Initiative
Our initiative to address hospital acquired pressure injuries in proned patients will take include a
number of approaches as there does not appear to be one specific cause of the event noted above.
First, we will emphasize the importance of pressure injury prevention and remind staff of the
progress we have made in the past when we focused on this issue. Next, we will continue to put
more emphasis on adequate staffing using this case as an example of some of the consequences
of inadequate staffing. We will also continue to reevaluate the devices we are using for
positioning our proned patients and will trial one or two new foam or gel devices. Due to how
common proned positioning has become during this pandemic, there is a recent increase in
literature related to prone positioning overall and related specifically to prevention of
complications that may result from prone positioning. While there is little in the way of direct
evidence of strategies that will decrease pressure injuries in COVID patients who are proned,
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Adverse Event Analysis 6
multiple organizations, vendors, and hospitals, along with these authors (Perrilat, 2020)
recommend using prophylactic dressings on all proned patients in an effort to mitigate risk.
There are numerous varieties of these dressings currently available as they have become more
common for prevention of heel and sacral pressure injuries in recent years. Many of these
dressings are available in a variety of sizes or can even be cut down to customized sizes and
shapes which makes it possible to use them on areas such the chin, cheeks, and forehead.
Conclusion
In conclusion, while there are numerous reasons why this particular patient was at very high risk
of developing pressure injuries, there are steps that we can take to decrease the risk in similar
patients in the future. Even though some pressure injuries may be considered unavoidable, they
should still be considered a serious event that we should do everything possible to prevent. There
is reason to believe that our incidence of pressure injuries will return to our baseline as our
number of COVID patients decreases so our interventions are focused on prevention specifically
in proned patients.
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Adverse Event Analysis 7
References
Barakat-Johnson, M., Carey, R., Coleman, K., Counter, K., Hocking, K., Leong, T., Levido, A., & Coyer, F. (2020). Pressure injury prevention for COVID-19 patients in a prone position. Wound Practice & Research, 28(2), 50–57. https://doi.org/10.33235/wpr.28.2.50-57
Perrillat, A., Foletti, J., Lacagne, A., Guyot, L., & Graillon, N. (2020). Facial pressure ulcers IN COVID-19 patients Undergoing prone Positioning: How to prevent an underestimated epidemic? Journal of Stomatology, Oral and Maxillofacial Surgery, 121(4), 442-444. doi:10.1016/j.jormas.2020.06.008
Pittman, J., Beeson, T., Dillon, J., Yang, Z., & Cuddigan, J. (2019). Hospital-acquired pressure injuries in critical and progressive care: Avoidable versus unavoidable. American Journal of Critical Care, 28(5), 338-350. doi:10.4037/ajcc2019264
Rafter, N., Hickey, A., Condell, S., Conroy, R., O'Connor, P., Vaughan, D., & Williams, D. (2014). Adverse events in healthcare: Learning from mistakes. QJM, 108(4), 273-277. doi:10.1093/qjmed/hcu145
The Joint Commission (2018). Managing medical device-related pressure injuries. Retrieved February 14, 2021, from https://www.jointcommission.org/resources/news-and- multimedia/newsletters/newsletters/quick-safety/quick-safety-43-managing-medical- devicerelated-pressure-injuries/
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,
Running head: ADVERSE EVENT ANALYSIS 1
Adverse Event or Near Miss Analysis
Capella University
Quality Improvement Interprofessional Care
Assessment 1
May 26, 2020
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ADVERSE EVENT ANALYSIS 2
Adverse Event or Near Miss Analysis
The missed steps or protocol deviations related to an adverse event or near-miss
To begin with, the adverse events and near-miss events are valuable learning occasions
and its evaluation aimed to improve the quality of patient care. One of the events that had
occurred and potentially could have caused irreversible consequences to the patient was an
undiagnosed hemorrhagic stroke. The patient with a history of injuries to the right side of their
body due to a car accident two years ago came to the emergency department. He reported fall at
home earlier in the morning. Upon arrival at the hospital's emergency department patient was
sent to the CT scan of his head but nothing remarkable was identified. The patient was admitted
due to complaints of right-sided weakness. Upon evaluation, there was a remarkable difference
in the patient's right upper extremity strength, range of motion, and noticeable weakness. Also,
the right lower extremity was weaker than the left. Due to the weekend and negative CT patient
‘s MRI scan was ordered as routine and was scheduled for the following day on Monday
morning. Meanwhile, nursing staff evaluated the patient every four hours using the NIH stroke
scale per admitting the doctor's order. The NIH score was 0 and the only deficits were weakness
and decreased range of motion recorded on the basic neuro assessment. Therefore, on Monday
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ADVERSE EVENT ANALYSIS 3
morning after the physician saw the patient their conclusion was to discharge the patient since
the patient have a pre-existing injury to the right side and there is no need to wait for the MRI but
if the nursing staff can try and expedite the MRI scan before discharge we can do it. Luckily for
the patient, the scan was done, and the radiology doctor called with the critical results – the
patient had an active hemorrhagic stroke. The discharge was canceled, and the patient was
provided with appropriate treatment.
This situation was based on the patient's medical history and not on a self-reported
change in condition and reliable test results. Doctors were quick to conclude that the reported
weakness and fall were related to the car accident two years ago and there is no need to follow a
healthcare organization protocol to rule out a stroke. This near-miss was prevented by following
standard steps and reliable diagnostic procedures. This event was reported to the charge nurse
that in turn informed the management. According to the data provided by the Joint Commission,
it is beneficial to report adverse or near-miss event since it helps in reducing risks of a similar
accident in the future, motivates the healthcare staff to implement initiatives for continuous
quality improvement performance, and simply alert the physicians to follow organization’s
protocols in order to promote harm mitigation (The Joint Commission, 2018).
The Implications of the Adverse Event or Near Miss for all Stakeholders
The short-term implications on the stakeholders are as followed:
– The patient and family – both were notified about the upcoming discharge and the
news about stroke was very unexpected. However, the patient was able to get the
appropriate medical care that reduced future harm.
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ADVERSE EVENT ANALYSIS 4
– The interprofessional team worked fast to provide the best patient care and ensure the
best patient outcomes. This included neurology consultation and follow up and
cardiology consultation due to the patient's uncontrolled hypertension.
The long-term implications can be more complex:
– The patient and family – according to the study of patients and their families who had
experienced near miss or adverse event performed by Ottosen and her team, had
found that long-term impact is very complex and harmful. “These effects unfold in
their homes, families, and communities, often long after they leave the hospital, and
can have huge individual and societal costs” Ottosen et al, 2018). In other words, the
realization of the potential harm affects individuals later in life and impact families
and patients psychologically, socially, and financially.
– The interprofessional team impact can be noticed in reflections and analysis of past
events. In other words, the involved healthcare team will answer the important
question "What can be done differently?" and self-reflection in the long-term can help
in preventing similar events.
The interprofessional team's responsibility and measures that should have been taken
include a review of policies and procedures and all the steps included in the ACLS guide related
to the stroke patient. In addition, the analysis will include evaluation of the particular case and
finding the reasoning to the fact that the patient's subjective feelings of weakness were not taken
seriously or basically ignored. An important change in the process of evaluation of the patient
with the rule out stroke will be avoiding any discharge until all the diagnostic tests are complete
to ensure the patient's safety and quality of care.
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ADVERSE EVENT ANALYSIS 5
Quality Improvement Technologies that are Required to Reduce Risk and Increase
Patient Safety
One of the quality improvement technologies that can help to reduce the risk of near-miss
events can be the utilization of the Electronic Medical Record. This form of technology can
promote patient safety. According to the research conducted by Waithera et al, there are five
significant advantages of the EMR. First of all, the record contains all the relevant information
which is patient specific. Secondly, by utilizing all the relevant information, healthcare
professionals can make an informed decision about patient care that includes recent laboratory
results, allergy history, and tests. The third benefit is related to healthcare provider order
management. New and even old prescription with specific doses and regimen are stored and
easily retrieved from the EMR. This advantage is an important milestone in reducing medication
administration errors and addresses an issue of polypharmacy. The fourth advantage is
addressing the quality of care improvement issues. Since EMR is a systematic and organized
platform, it allows better evaluation and analysis of patient-specific care which in turn helps in
identifying new health conditions and symptoms. The fifth benefit allows to "…facilitate
exchange of electronic information. EMR systems co-exist with other systems in the health care
system. These include other EMR systems, laboratory systems, and pharmacy systems” (2017, p.
2).
By appropriately utilizing the existing technology the interprofessional healthcare team
can make an informed decision about the patient's condition and improve the quality of patient
care. In addition, based on the patient's suspected diagnosis, the electronic medical record can
include a virtual checklist or build-in diagnostic tests that are required prior to the patient being
discharged. This checklist will follow the organization's standard protocols.
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ADVERSE EVENT ANALYSIS 6
Relevant Metrics of the Adverse Event or Near Miss Incident
The concept of harm prevention or simply not causing any harm to the patient has a long
history. The most known reports To Err is Human back in the 90s raised the public's attention to
this matter and healthcare organizations implemented various initiatives to evaluate and decrease
any human-caused medical errors. According to the Agency of Healthcare Research and Quality,
the most effective key performance indicators and metrics of the adverse events or near miss
based on near-miss report system. It is proven that developing an open and trusting relationship
between medical staff and management helps in preventing future mistakes and facilitates better
communication. Also, Wang & Yan in their case study describes the causation model and state
that adverse events and near misses forerunners to more serious medical errors (2019).
“Examining near misses provides two types of information relevant for patient safety: (1) that on
weaknesses in the health care system (errors and failures, as well as inadequate system defenses)
and (2) that on the strengths of the health care system (unplanned, informal recovery actions)
which compensate for those weaknesses on a daily basis, often making the essential difference
between harm and no harm to a patient “ (Wang & Yan, 2019). This information can be
generated from the healthcare facilities’ dashboard and helps with analysis and modifications of
the healthcare approach that ensures higher quality and safe patient care.
Quality Improvement Initiative to Prevent Future Adverse Event or Near Miss
Quality improvement is the ultimate goal of the healthcare organization. To better define
the improvement process, the report system of the near-miss event must be improved, and the
relevant data evaluated. This will allow better analysis and further understanding of the event
with future development of the steps to prevent a similar occurrence.
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ADVERSE EVENT ANALYSIS 7
The current protocol that is related to the patients with rule out stroke includes step by
step and time-sensitive patient ca