30 Jan Number of references:

Question
Unit 03 Assignment 1

Adverse Event or Near Miss Analysis

Professional Context

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.

Reference

National Quality Forum. (2009). NQF Patient safety terms and definitions. Retrieved from http://www.qualityforum.org/Topics/Safety_Definitions.aspx

Instructions

Prepare a comprehensive analysis on an adverse event or near miss from your professional nursing experience that you or a peer experienced.

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.

The bullet points below correspond to grading criteria in the scoring guide. Be sure that your analysis addresses all of the bullets below. 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 grading criterion. Additionally, be sure to review the Guiding Questions: Adverse Event or Near Miss Analysis document, linked in the resources, for additional clarification about things to consider when creating your assignment.

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.

Example assignment: You may use the Adverse Event or Near Miss Analysis Example, linked in the Resources, to give you an idea of what a Proficient or higher rating on the scoring guide would look like.

Submission Requirements

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.

APA formatting: Resources and citations are formatted according to current APA style.

Turnitin: It is suggested, but not required, that you submit your paper to Turnitin before you submit it for grading. Turnitin will help ensure that you have used resources ethically and effectively. Use the link located in the Resources for more information and to view job aids for using Turnitin.

Resources

Adverse Event or Near Miss Analysis Scoring Guide.

WebM&M Cases & Commentaries.

TurnItIn.

Guiding Questions: Adverse Event or Near Miss Analysis [DOC].

APA Module.

Adverse Event or Near Miss Analysis Example.

Unit 06 Assignment 1

Quality Improvement Initiative Evaluation

Professional Context

Too often, discussions about quality health care, care costs, and outcome measures take place in isolation—each group talking among themselves about results and enhancements. Because nurses are critical to the delivery of high-quality, efficient health care, it is essential that they develop the proficiency to review, evaluate performance reports, and be able to effectively communicate outcome measures related to quality initiatives. The nursing staff’s perspective and the need to collaborate on quality care initiatives are fundamental to patient safety and positive institutional health care outcomes.

Instructions

You have been asked to prepare and deliver an analysis of an existing quality improvement initiative at your workplace. The QI initiative you choose to analyze should be related to a specific disease, condition, or public health issue of personal or professional interest to you. The purpose of the report is to assess whether or not specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Your target audience is nurses and other health professionals with specializations or interest in your chosen condition, disease, or public health issue.

In your report you will:

Define the disease.

Analyze how the condition is managed.

Identify the core performance measurements related to successful treatment or management of the condition.

Evaluate the impact of the quality indicators on the health care facility.

Be sure to address the bullet points below in your analysis, as they correspond to grading criteria in the scoring guide. You may also want to read the Quality Improvement Initiative Evaluation Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Quality Improvement Initiative Evaluation document, linked in the resources, for additional clarification about things to consider when creating your assignment.

Analyze a current quality improvement initiative in a health care setting

Evaluate the success of a current quality improvement initiative through recognized benchmarks and outcome measures.

Incorporate interprofessional perspectives related to initiative functionality and outcomes.

Recommend additional indicators and protocols to improve and expand outcomes of a quality initiative.

Communicate evaluation and analysis 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.

Example assignment: You may use the Quality Improvement Initiative Evaluation Example, linked in the Resources, to give you an idea of what a Proficient or higher rating on the scoring guide would look like.

Submission Requirements

Length of submission: A minimum of five but no more than seven double-spaced, typed pages.

Number of references: Cite a minimum of four sources (no older than seven years, unless a seminal work) of scholarly or professional evidence to support your interpretation and analysis.

APA formatting: Resources and citations are formatted according to current APA style.

Turnitin: It is suggested, but not required, that you submit your paper to Turnitin before you submit it for grading. Turnitin will help ensure that you have used resources ethically and effectively. Use the link located in the Resources for more information and to view job aids for using Turnitin.

Resources

Quality Improvement Initiative Evaluation Scoring Guide.

APA Module.

Guiding Questions: Quality Improvement Initiative Evaluation [DOC].

TurnItIn.

Quality Improvement Initiative Evaluation Example.

Unit 09 Assignment 1

Data Analysis and Quality Improvement Initiative Proposal

Professional Context

“A basic principle of quality measurement is: If you can’t measure it, you can’t improve it” (Agency for Healthcare Research and Quality, 2013).

Health care providers are on an endless quest to improve both care quality and patient safety. This unwavering commitment requires hospitals and care givers to increase their attention and adherence to treatment protocols to improve patient outcomes. Health informatics, along with new and improved technologies and procedures, are at the core of virtually all quality improvement initiatives. The data gathered by providers, along with process improvement models and recognized quality benchmarks, are all part of a collaborative, continuing effort. As such, it is essential that professional nurses are able to correctly interpret, and effectively communicate information revealed on dashboards that display critical care metrics.

Reference

Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals. Retrieved from https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html#tiptop

Instructions

In this assignment, you will propose a quality improvement initiative proposal based on a health issue of professional interest to you. The QI initiative proposal will be based on an analysis of dashboard metrics from a health care facility. You have one of two options:

Option 1

If you have access to dashboard metrics related to a QI initiative proposal of interest to you:

Analyze data from the health care facility to identify a health care issue or area of concern. You will need access to reports and data related to care quality and patient safety. If you work in a hospital setting, contact the quality management department to obtain the data you need.

You will need to identify basic information about the health care setting, size, and specific type of care delivery related to the topic that you identify. You are expected to abide by standards for compliance with the Health Insurance Portability and Accountability Act (HIPAA).

Option 2

If you do not have access to a dashboard or metrics related to a QI initiative proposal:

You may use the hospital data set provided in the Vila Health: Data Analysis presentation to identify a health care issue or area of concern.

You will follow the same instructions and provide the same deliverables as your peers who select Option 1.

The bullet points below correspond to grading criteria in the scoring guide. Be sure that your proposal is, at minimum, addressing each of the bullets. You may also want to read the Data Analysis and Quality Improvement Initiative Proposal Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Data Analysis and Quality Improvement Proposal document, linked in the resources, for additional clarification about things to consider when creating your assignment.

Analyze data to identify a health care issue or area of concern.

Outline a QI initiative proposal based on a selected health issue and supporting data analysis.

Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work-life quality.

Apply effective communication strategies to promote quality improvement of interprofessional care.

Communicate evaluation and analysis 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.

Example assignment: You may use the Data Analysis and Quality Improvement Initiative Proposal Example, linked in the Resources, to give you an idea of what a Proficient or higher rating on the scoring guide would look like.

Submission Requirements

Length of submission: 8-10 double-spaced, typed pages, not including title and reference page.

Number of references: Cite a minimum of five sources (no older than seven years, unless a seminal work) of scholarly or professional evidence to support your evaluation, recommendations, and plans.

APA formatting: Resources and citations are formatted according to current APA style.

Turnitin: It is suggested, but not required, that you submit your paper to Turnitin before you submit it for grading. Turnitin will help ensure that you have used resources ethically and effectively. Use the link located in the Resources for more information and to view job aids for using Turnitin