NURS FPX 6016 Assessment 1

NURS FPX 6016 Assessment 1

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

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In healthcare, patient safety remains at the highest level of the priority scale. Nevertheless, the amount of energy for the system of safety as the normative factor does not prevent adverse events and near misses to be the most costly problems. This can add to the burden on patients, relatives, healthcare providers and healthcare facilities, thereby causing great concern. In the medical field, health workers must evaluate such events carefully so as to find out the root cause and corrective actions and implement methods so that they can be prevented in future. This Analysis of Adverse Events or near misses has been designed to investigate any single incident that might have occurred in real life or to a person. It will examine the results of this incident, the sequence of events and its root causes. Conducting a systematic review can give us the necessary information about the causes of the event, and from this data, quality improvement activities to enhance patient safety could be designed to provide high-level safety care. The outcome of the discussion includes how a healthcare incident can alter the narrative amid the behaviour of several stakeholders, such as the patients, their family members, the interprofessional team, and the healthcare facility (Smith et al. , 2020). We will also be analysing the chain of events acted upon that has eventually resulted in the adverse event or near miss by employing root cause analysis frameworks for the purposes of spotting potential avenues for improvement.

Implications of the Adverse Event for Stakeholders

When there is the occurrence of a critical event or deficiency in a healthcare establishment, the feelings of different groups involved show different emotions, and those who are experiencing different kinds of outcomes (Johnson et al. , 2020). The long-term aftermath may result in medical problems that last for a long time, financial hardships, and psychological injuries that don`t disappear easily (Smith & Jones, 2019). Furthermore, the layperson may experience panic; the thought of previous healthcare encounters may consume them several times, making them reluctant to seek medical care or even comply with recommended treatments.

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

Facing adverse events or near misses, health professionals have a lot of difficulties that are complicated enough for them to correctly figure that out because of various reasons. They usually struggle with guilt, shamefulness, and real disquiet, regarded as a consequence of their calling influence on patient safekeeping (Garcia, 2021). Inter-professional teams would be under stress raised to a new level; they would try their best to solve the problem up to the point of burnout and even in the end, they would feel uncomfortable about the work that they got assigned to them (Lee, Brown, 2020). Moreover, healthcare providers might not only be exposed to defamation but they could also face public damage to their reputation and professional consequences that would negatively impact of their careers as well as their relations with patients and colleagues.

Adverse Event with Root Cause Analysis

Analyzing the complex chain of events, omissions or protocol deviations connected to an adverse event or a possible error by root cause analysis is a necessary and sufficient condition for understanding the fundamental factors that have caused the incident that happened (Smith et al. ,2020). Thus, pinpointing the root causes of healthcare issues allows healthcare agencies to plan special interventions to maintain more conducive work environment. With RCA, which stands for “Root Cause Analysis,” serves as the pivotal methodology being applied and administrated by healthcare professionals, who are being guided through a logical reasoning route (Jones & Brown, 2019). In the beginning, the RCA procedure is focused on reviewing the record of documented medical procedures and reporting for adverse events or near-miss, compilation of data from the reports and the interviews with the involved parties (Johnson et al. , 2021). Such great documentation pinpoints focal points that constitute milestones and minor breakdowns with stipulated highlights on the timeline. Subsequently, the focus of the identification stage will be on the gaps, oversights or deviations from already established protocols. Such deviations, such as human errors, communication breakdown, and wrong prescriptions, can be critical points in time where interventions at the right time can help reduce the stiff consequences of the adverse event (Lee & Miller, 2022). On the other hand, RCA looks into what might be the root-causes for these deviations. It extensively explores individual actions, organisational system failures, systemic problems, cultural issues and environmental issues.

NURS FPX 6016 Assessment 1

Evaluation of Quality Improvement Technologies Related to the Event

Assessment and determination of quality improvement approaches or technologies relating to a consequence or close call incident is imperative for the reduction of risks and for achieving improved patient security within healthcare organisations. The utilisation of grounds that are knowledge-based and innovative can help the health care teams to come up with interventions that will minimise the occurrence of the same as well as the reoccurrence of the events in the future.

  • Medication Reconciliation Systems:

Such systems, including medication reconciliation platforms, may be of help to reduce medication errors, one of the main causes of adverse events in hospital settings (Jones et al., 2020). These systems involve Electronic Health Records (EHRs) and barcode scanning to ensure not only that medication lists are correct but also that they are reconciled and that drug interactions with allergies are given alerts in real-time. The correct implementation of medication safety techniques helps to prevent cases of adverse drug events as well as leads to favourable results for the patient.

  • Clinical Decision Support Systems:

Clinical decision support systems (CDSS) have the ability to offer Drs care guidelines, alarms, and reminders at the point of touch (Smith & Brown, 2019). They use smart algorithms and data analytics and help doctors make rational judgments, fewer misdiagnoses and improve treatment plans. Through fostering respect for great and detailed care measures and accredited guidance, CDSS enables safe patients and unwanted events related to clinical decision-making to be avoided.

Quality Improvement Initiative to Prevent a Future Adverse Event or Near Miss

A comprehensive quality improvement initiative should be developed based on the research and practices confirmed by the evidence to avoid repeating a particular event or a close call. This practice should be based on the main guidelines of patients’ safety, risk management, and continual improvement (Jones et al., 2020). First and foremost, performing a detailed needs assessment will be important to determine those areas within the organisation that are vulnerable and how the risks could arise (Smith & Brown, 2019). Evaluating the incident reports, the near misses reports, and the adverse events data allows to detect recurrent patterns or trends. Further, byallaying information from staff on the ground, health care providers and other stakeholders, a lot of valuable information on where adjustments are required can be acquired. Secondly, it is vital to set up clear and measurable targets that the improvement initiative aims to achieve, and they must correspond with the organisation’s strategic goals and priorities (Lee & Wilson, 2021). Set clear goals of minimising the rate of adverse happening or near misses within span of one year to direct the initiative effectively. Establishing what interventions and best practices have been shown to greatly improve patients’ safety and eliminate the chance of adverse events would be another very important step (Garcia et al. , 2020). Illustrated approaches can be documentation of clinical protocols and procedures, the introduction of medication safety initiatives, improvement of communication and teamwork structure, the introduction of technology solutions, and the establishment of a comprehensive quality assurance system.


In conclusion, the unfolding of adverse events or close misses in healthcare institutions plays a vital function in recognizing the areas that need improvements and implementing the action measures that would enhance the safety of patients. Through an extensive examination of all incidents and their root causes, along with evidence based interventions, healthcare institutions can minimize risks and avoid the while occurrence of similar events in future. This essay has furnished the stakeholders with the impact of the adverse events or near misses; this includes patients, families, healthcare providers, the organisation, and others. Furthermore, we have been using root cause analysis methodology in the process of sequential events that lead to incidents, uncovering the missing steps or deviations from protocols which were the major contributing factors. Lastly, relevant methods for quality improvement and technologies related to those events, like medication reconciliation systems, clinical decision support systems, and simulation programs have been assessed by our team. They are sporadically used to minimise risks and promote better patient safety within medical facilities.

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