MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis Example 1

Analysis of a Near Miss or Adverse Nursing Event

Adverse events lead to fatal patient outcomes, while near misses are opportunities to improve healthcare delivery processes and prevent adverse events from occurring. Adverse events are a leading cause of death among emergency department patients. They cause premature death and preventable patient morbidity. Adverse events should be followed by quality improvement interventions to prevent the recurrence of these events in the future. This essay focuses on developing quality improvement interventions to prevent the recurrence of an identified adverse event.

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis

A 64-year-old schizophrenic male in the psychiatric ward started complaining of severe shortness of breath, severe weakness, nausea, vomiting, and severe cramping, which began a day ago with increasing severity. The doctor diagnosed him with hypokalemia (2.8mmol) and noted he was on long-term management of schizophrenia with Risperidone and Quetiapine. The doctor prescribed a 200mEq potassium infusion for six hours (a flow rate of 33mEq/h).

The nurse in the psychiatric ward, a newly employed nurse in her first week in the ward, panicked at seeing the condition of the man. She quickly infused the patient with the prescription, left it running, and attended to other patients. After an hour, the nurse came back to find the patient still and cold. Postmortem results revealed that the patient died from fatal arrhythmias, and a lethal dose of potassium was found in the blood.

ASSESSMENT_1_Adverse_Event_or_Near-Miss_Analysis_Scoring_(_RUBRIC)

Assignment1_Adverse_Event_or_Near-Miss_Analysis_Instructions

Analysis of Missed Steps and Protocol Deviations Related to the Adverse Event

Some major causes of errors include panic, insufficient knowledge, confusion, and professional negligence (Senders, 2018). In clinical settings, errors may be chronic or acute, and a single error leads to a series of errors that lead to morbidity or mortality. A root cause analysis identified several missed steps.

Risperidone and quetiapine are antipsychotic medications administered to schizophrenic patients. These drugs are prone to causing hypokalemia, and thus, patients are monitored for hypokalemia (Yang, Guo, & Lee, 2018). The patient’s potassium levels were not monitored, dropping far below the normal range. Normally, if these drugs lead to hypokalemia, they are changed to her therapies such as amisulpride.

Another error was that the nurse administered the drug bypassing the IV infusion pump, hence major errors in flow rate. The nurse panicked after realizing the errors committed, which led to further errors. In addition, the nurse did not monitor the drug flow rate and did not pay attention to the prescription.

Potassium is a slow IV, and administering it as a bolus or fast has lethal effects, as it occurred in this case (Du, Mou, & Liu, 2019). The patient under Potassium infusion was not monitored on the ECG as stipulated by the organizational policies. He was left unmonitored, violating the organizational protocols. If these policies were implemented, the adverse event would have been effectively prevented from the various opportunities in the event.

Effects of the Adverse Event on the Various Stakeholder

Adverse effects have various effects on the various stakeholders. These are the patients and their families, healthcare providers, and the organization. The organization is tasked with educating staff on the management of various medications. The organization is also responsible for increasing the vigilance of its staff through proper training. The organization suffers from such adverse events greatly. The organization’s reputation is always at stake.

Adverse events soil an institution’s reputation. A bad reputation drives clients away in fear of similar events from occurring to them. Clients may also give a poor patient satisfaction rate, significantly affecting an organization’s accreditation. These poor results also reduce the remuneration by insurance such as Medicaid, whose payment is based on the perceived quality of services. In addition, the institution may incur high lawsuit costs from legal proceedings if the patient’s family decides to sue the organization.

The interprofessional team maintains patient safety through collective decision-making and quick and informed consultation. The team is responsible for reviewing care and ensuring all patients receive the right care, which did not happen. The interprofessional team is also exposed to several effects, such as retrenching members or the whole team following a disciplinary hearing. Most often, the institutions dismiss interprofessional team members found guilty. In some instances, healthcare providers have been charged with murder and found guilty, and they spend time in jail or pay hefty fines.

Healthcare providers who are jailed suffer from ruined careers and have difficulties nursing their careers even after completing the jail terms (Tigard, 2020). In addition, the organization may also punish these healthcare professionals as per the stipulation of the organizational policies, such as suspension or paying for the damages in cases of incurred healthcare costs. The staff may also be overcrowded by the guilt of having killed or maimed an individual, negatively affecting their career life (productivity and job satisfaction) (Tigard, 2020).

The patient is the most affected stakeholder in adverse events. Patients should participate in their care by following instructions, asking questions, and seeking clarity before taking drugs and other interventions. However, in most adverse events like this, patients cannot prevent such events beyond their roles.

The patients suffer from high healthcare costs from healing preventable errors (Carver et al., 2021). In some instances, such as this case, patients die and cause grief to their families. Experiencing near-miss events also affects an individual’s care-seeking behavior and discourages them from seeking healthcare services in the future due to fear (Carver et al., 2021). Fear may also prevent families from seeking healthcare services.

All healthcare professionals, organizations, and patients must promote patient safety and prevent these sentinel events from occurring (Godshall & Riehl, 2018). Healthcare professionals were expected to share their roles in inpatient care, and the other nurses should have also helped monitor this patient. Care collaboration improves the quality of care and immediacy and promotes patient safety.

The doctor should have followed the patient to see their progress and determine if they received the prescribed medications. This nurse was left unsupervised, and she lacked proper knowledge of handling medications and organizational policies regarding medication administration. The department leader should have adequately oriented the nurse to her roles and assigned a supervisor to ensure safe practice. These activities would have effectively prevented the adverse event from happening.

The healthcare institution developed some interventions to prevent such events from happening in the future. The institution management instructed that every medication procedure be carried out with an assistant. Using assistants reduces medical errors significantly and enhances the responsibility of healthcare providers (Gomes et al., 2021). The healthcare institution passed the regulation and included it in the organizational policy. The policy also requires that all nurses who provide care without consultation receive disciplinary action relative to the severity of their actions. The policy change has significantly improved the nurses’ vigilance, responsibility, and subsequent efficacy.

Evaluation of Quality Improvement Technologies

The major effects of adverse effects and sentinel events are increased mortality and morbidities such as paralysis, organ failure, and mental health issues. Healthcare data is integral in planning patient care. Healthcare technologies help improve healthcare efficiencies and promote patient safety. Some leading healthcare technologies are computerized provider order entry (CPOE) and the clinical decision support systems (CDSS).

CPOE helps professionals use standardized drug ordering systems, while the CDSS helps healthcare providers make informed decisions by availing the required disease of drug-specific information (Angela & Adisasmito, 2019). The CPOE and the CDSS would have helped prevent the errors, such as the missed ECG monitoring, thus preventing the event.

Healthcare quality improvement projects are based on well-prepared goals and objectives that help evaluate and ensure their success. Healthcare dashboards are healthcare technology-based programs that help institutions determine their position relative to achieving the local, state, and federal regulations set goals and objectives.

Dashboards help organizations to remain focused on maintaining high-quality care and patient safety (Kunjan et al., 2019). Dashboards and CDSS systems guide professionals in decision-making by ensuring their decisions are well-informed and are aligned with the organizational goals and objectives. Dashboards and other healthcare technologies, such as CDSS and CPOE could significantly improve healthcare efficiencies.

Relevant Metrics for the QI

Dashboards rely heavily on key performance indicators based on patient-clinician relationships. Electronic health records provide information on these processes and outcome key performance indicators. Many institutions, such as the Agency for Healthcare Research and Quality, control patient care and the Institute of Medicine (IOM) are concerned with healthcare improvement. AHRQ develops and enforces national dashboard metrics allows organizations to create their dashboards and work towards achieving the nationally set benchmarks.

Through the National Inventory of Mental Health Quality Measures, AHRQ sets national benchmarks to help healthcare professionals ensure patient safety in psychiatric wards. These include measures such as the proportion of psychiatric patients who developed severe side effects, the percentage of patients educated, the proportion of psychiatric patients admitted for specialized care, and the mean duration between seeking and receiving healthcare services (AHRQ, n.d.). The metrics specific to medication errors include the type, cause (process, underlying condition, patient, or care provider), and severity (mild to severe) (AHRQ, 2021).

Examples of metrics relevant to this institution would include a) the mortality rates from uncomplicated diseases, b) medication errors death and mortality rates, c) the percentage follow-ups accomplished, and d) medication errors near-miss reports (AHRQ,n.d.). As mentioned earlier, healthcare technologies combined with well-prepared dashboard metrics will help the organization promote high-quality decisions, better healthcare efficiencies, patient safety, and thus, quality improvement.

Dashboards are important to healthcare institutions in various ways. They act as evaluation tools, motivate staff, assist in rational decision-making, provide room for personal improvement, they increase staff morale, accountability, and responsibility, thus improving healthcare efficiencies (Kunjan et al., 2019; Isazan et al., 2020; Pestana et al., 2020).

Quality Improvement for the Hospital

The IV drug pump, a bedside ISBAR patient handing-over tool, and medication companions are current evidence-based strategies that help reduce errors (Carver, Gupta & Hipskind, 2021). Medication companions help improve efficiency by accurately reading and interpreting orders with improved knowledge and decreased error chances. IV drug pumps help reduce dosage, frequency, and flow rates errors. Handing patients by the bedside makes nurses familiar with the patients’ unlike handling over at the nurses’ station.

Several quality improvement models can be applied in healthcare settings, including the Donobedian, PDSA, and the LEAN Six Sigma DMAIC models (Goldman et al., 2021). The Donobedian model focuses on the progress of the QI project. The PDSA focuses on determining problems and helps plan strategies to address the issues. However, it does not determine the causes of errors to help address them. LEAN thinking and the Six Sigma DMAIC model focus on the causes of errors and develop cause-specific strategies to address these problems (AHRQ, 2021). The model is thus the most ideal in creating the QI outline.

From the seen interventions and research, the QI interventions outline will highly benefit from the LEAN thinking and Six Sigma DMAIC model, dashboard program, and the healthcare technologies (CDSS and CPOE) to support decision making and improve healthcare efficiency. These components will help create a strong quality improvement initiative that will help prevent other adverse events from occurring in the future. In addition, these components can be utilized in all hospital departments to promote patient safety and high-quality care.

Conclusion

Healthcare institutions still suffer the burden of medication errors. They lead to various consequences, such as morbidities and, at times, death, as seen above. While medication errors seem unpredictable, they can be avoided by increased vigilance and better healthcare technologies and strategic planning. Current initiatives such as healthcare dashboards can help improve healthcare efficiencies.

In addition, other healthcare technologies, such as the CPOE and CDSS systems, can help improve healthcare delivery and promote professional practice. The Six Sigma model is ideal for developing QI initiatives in healthcare settings. Healthcare leaders should invest in investigating adverse effects and identifying strategies to prevent the recurrence of these errors in the future.

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis References

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis Instructions

Prepare an analysis (5-7 pages) of an adverse event or a near miss from your professional nursing experience and outline a QI initiative that would address it.

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis Instructions

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis

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 grading criterion. Additionally, be sure to review the Guiding Questions: Adverse Event or Near Miss Analysis [DOCX] document for additional clarification about things to consider when creating your assessment.

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis Sample Approach 2

Introduction

Re-envisioning the widespread commitment and the diagnostic process is critical to illuminate the diagnostic error’s blind spots and improve healthcare diagnosis. Diagnostic errors are increasingly growing and are becoming a serious issue in the healthcare unit, and there seems to be not much that can be done to bring a change. However, despite the increasing cases of diagnostic errors, the hospitals must make a few recommendations to ensure they improve patient outcomes and address other challenges. This paper will focus on a misdiagnosis case in my workplace and describe stakeholders’ implications to provide functional recommendations to resolve the issue.

I will share my colleague’s experience with a mid-aged woman, Mrs. Johnson, who had a rectal bleeding problem. In her case, the doctor conducted a limited sigmoidoscopy test, which came out negative. The bleeding, on the other hand, did not stop even after she underwent numerous treatment methods. After about two years, the patient’s condition worsened, and she had to return to the facility. As per her assessment, she had lost at least 10 kgs within that time.

After further evaluation of her condition, the doctor diagnosed her with colon cancer, which was at a relatively advanced stage. The doctor indicated in his assessment that based on the previous medical record, the issue could have been identified earlier when there were still chances for a cure. However, the event was ruled adverse due to the medical negligence she had encountered previously.

Analysis of the Missed Steps That Lead To the Adverse Events

A bright bleeding per rectum is a common clinical issue that adults of all ages often experience. However, when it comes to young adults, the issue is not well reported, causing an assumption that it is not common for a particular age group (Segev et al., 2018). In this regard, doctors need to perform a colonoscopy within the first time of diagnosis to evaluate rectal bleeding considering that it could present multiple risks of colorectal neoplasms. According to Jodal et al. (2019), at least 10% of patients with rectal bleeding have been diagnosed with colorectal cancer. It would have also been helpful for the doctor to consider other options in his testing, such as adenomatous polyps.

Another reason this was considered an adverse event was because the doctor would have conducted further tests when the patient expressed that the bleeding was still there rather than expecting the issue to magically disappear. The doctor failed to test for neoplastic lesions, which are located in the distal colon of almost all patients with rectal bleeding. There is also a possibility of patients having hemorrhoids and adenocarcinoma in the transverse colon. The doctor should have also considered tumors as a reason for the bleeding, hence conducting a colonoscopy to rule out the issue (Jodal et al., 2019).

The distribution of polyps is very similar to that of colorectal cancer patients. Therefore, the doctor’s job was to ensure they ran a comprehensive test and considered a few possibilities. Rigid sigmoidoscopy is a diagnostic procedure used to rule out colorectal pathology (Segev et al., 2018). It is frequently performed in outpatient clinics and requires minimal intestinal preparation. On the other hand, flexible sigmoidoscopy is a more advanced test with a higher diagnostic value and less patient discomfort than a rigid sigmoidoscopy.

As for the case of Mrs. Johnson, a middle-aged patient, it would have been convenient to get her screened for colorectal cancer. The patient and the doctor should have also had an agreement on the appropriate tests between sigmoidoscopy and colonoscopy that will be effective and bring the necessary result. Data provided by Segev et al. (2018) indicate that at least 90% of the patients in the clinic are flexible to take sigmoidoscopy, which is clinically significant.

On the other hand, those who may opt for a colonoscopy are also guaranteed that the test is effective and will bring convenient results for those who need colorectal cancer screening and are above the age of 50 years (Cheluvappa & Selvendran, 2020). It would also be convenient to investigate whether any visible cultural differences between the patient and the physician could have impacted the course of treatment. The difference in cultural understanding directly influences the treatment approach for various patients.

Implications of Medical Negligence of Stakeholders

Patients have an ethical responsibility toward their health and the cost regulations. However, the regulations cannot effectively be implemented or strictly force people into living a healthy lifestyle. By embracing a healthy lifestyle, it is guaranteed that the cost of healthcare will be significantly reduced. On the other hand, it is critical for people with medical insurance to have the best insurance cover possible to make them comfortable, especially with the current expansion of innovation.

The doctors, conversely, are expected to ensure they provide the expected services to their target clients. However, it is also convenient to understand that the best medical services should not necessarily be expensive. Therefore, the doctors and the patients are expected to work together and ensure they reach a sensible health decision. As for the case of Mrs. Johnson, it would have been best for her to visit the doctor as soon as she noticed the issue had not been resolved rather than waiting all that long.

Additionally, considering that she was not satisfied with the conclusion of the previous doctor, it would have been best for her to seek a second and third opinion. The short-term consequences of the near-miss incident were low customer satisfaction, which resulted in a reduction in the number of patients served by the hospital. The problem could result in significant losses in the long run.

Customers would cease coming to the hospital, and there is a considerable risk of legal action, which would result in financial losses. The problem will be remedied by immediately treating the patient and finding measures to reimburse her for the initial misdiagnosis (Sapoelete et al., 2021). For example, the hospital could agree to pay for all of her future treatments, whether they occur at the hospital or elsewhere.

Interprofessional Team

Patients depend on interprofessional team intervention to receive reliable care and monitor the rise in healthcare costs. However, on the part of the interprofessional team, they often have limited time to attend to specific patients and review their specific medical charts due to the increasing number of patients and the high cost of healthcare. Such issues have contributed to the increased cases of medical negligence (Cheluvappa & Selvendran, 2020). Health professionals are committed to doing everything possible for the patient’s benefit. Doctors are expected to make decisions on their own, with little regard for the interests of their patients. Even while they act freely, the interprofessional team should respect patients’ rights while deciding on the best care for them.

Community

A community’s role is to guarantee that all patients receive the greatest treatment options possible. The community owes it to health practitioners to push them to offer the appropriate degree of treatment for all patients, regardless of insurance or cost, while also addressing their needs (Curtis et al., 2021). The community’s responsibility is to ensure that all patients, affluent and poor, receive equal treatment while seeking medical care.

Diagnosis and Technologies

Understanding the patient’s information in detail regarding diagnosis and treatment is critical. Therefore, the physician has to ensure they use the best and most relevant technology that will help in the diagnosing and treatment process to guarantee improved patient outcomes. With the best technology, physicians can lower the cost of treatment and reduce the time spent on specific patients (Carayon & Hoonakker, 2019). In the case of Mrs.

Johnson, there is a higher possibility that her condition was not discovered earlier due to a lack of proper inclusion of technology in the diagnosis process. In the healthcare setting, service delivery largely depends on collecting, storing, and analyzing patient information. Therefore, when it is not done effectively, the service delivery will be impaired, affecting the patient outcome. To achieve better results, using technology such as Health Information System (HIS) guarantees better clinical data collection and storage, improving patient care outcomes (Sapoelete et al., 2021).

The technology helps physicians capture specific patient information and minimize the risks of duplicating patient information, preventing misdiagnosis. HIS is also easy to use and super friendly to the users. Regarding maintenance, the technology is relatively straightforward and does not attract huge costs.

Metrics for Adverse Event Support

Cases of medical errors are increasingly growing, affecting people from across all age groups. Each year, nearly 230000 people die as victims of medical negligence (Anderson & Abrahamson, 2018). During my practice, I have witnessed at least seven deaths resulting from our staff malpractice. Studies further show that at least one in every 70 cancer cases results from misdiagnosis within the appropriate time when there are chances of getting treatment.

Still, due to late discovery, the problem escalates, making it difficult to resolve. The late discovery of the disease makes it escalate into a severe stage where the treatment process will be ineffective and costly for the patient (Carayon & Hoonakker, 2019). Therefore, caregivers must conduct proper and detailed diagnoses to minimize or eliminate misdiagnosis. It is also critical to evaluate the depth of the mistake and identify positive and effective ways to correct the issue.

Recommendation

Such problems can be prevented if health devices and technology are properly used. In the healthcare industry, the introduction of computers and other devices has greatly increased the amount of patient data stored at one time. Furthermore, continuously updating devices provides accurate prescriptions and medicine even when symptoms change (Curtis et al., 2021). With the use of technology, all patient information will be accessible, making it simple for caregivers to locate in an emergency.

Consequently, Mrs. Johnson’s condition would have been handled differently if the initial physician who attended to her case had used technology during the diagnosis procedure. If one physician cannot diagnose properly, technology assures that another can. Team collaboration is also necessary to achieve evidence-based quality improvement through sharing essential patient information for enhanced decision-making.

Conclusion

As per the case of Mrs. Johnson, medical negligence made it difficult for her to access professional assistance when she needed it the most. Doctors and patients have a role in handling the issue of medical negligence. Therefore, it is critical to formulate a functional relationship and guarantee that the issues leading to errors are resolved. The health institutions also have a role to play in ensuring improved patient outcomes.

MSN-FP6016 Assessment 1 Adverse Event or Near Miss Analysis References

Anderson, J. G., & Abrahamson, K. (2018, January). Your Health Care May Kill You: Medical Errors. In ITCH (pp. 13–17). doi 10.1007/s10729-009-9111-1.

Carayon, P., & Hoonakker, P. (2019). Human factors and usability for health information technology: old and new challenges. Yearbook of Medical Informatics, 28(01), 071-077 DOI: 10.1055/s-0039-1677907.

Cheluvappa, R., & Selvendran, S. (2020). Medical negligence-Key cases and application of legislation. Annals of Medicine and Surgery, 57, 205-211. https://doi.org/10.1016/j.amsu.2020.07.017

Curtis, N. J., Dennison, G., Brown, C. S., Hewett, P. J., Hanna, G. B., Stevenson, A. R., & Francis, N. K. (2021). Clinical evaluation of intraoperative near misses in laparoscopic rectal cancer surgery. Annals of Surgery, 273(4), 778–784. doi: 10.1097/SLA.0000000000003452

Jodal, H. C., Helsingen, L. M., Anderson, J. C., Lytvyn, L., Vandvik, P. O., & Emilsson, L. (2019). Colorectal cancer screening with fecal testing, sigmoidoscopy or colonoscopy: a systematic review and network meta-analysis. BMJ Open, 9(10), e032773. http://dx.doi.org/10.1136/bmjopen-2019-032773

Sapoelete, R., Muhadar, M., Yudianto, O., & Budiarsih, B. (2021). The Concept of Penal Mediation for the Crime of Medical Negligence in Realizing Legal Protection for Medical Personnel and Patients or Their Families. International Journal of Multicultural and Multireligious Understanding, 8(2), 147-151. DOI: http://dx.doi.org/10.18415/ijmmu.v8i2.2406

Segev, L., Kalady, M. F., & Church, J. M. (2018). Left-sided dominance of early-onset colorectal cancers: a rationale for screening flexible sigmoidoscopy in the young. Diseases of the Colon & Rectum, 61(8), 897-902. doi: 10.1097/DCR.0000000000001062

Sinha, M., Jupe, J., Mack, H., Coleman, T. P., Lawrence, S. M., & Fraley, S. I. (2018). Emerging technologies for molecular diagnosis of sepsis. Clinical Microbiology Reviews, 31(2), e00089-17. DOI:https://doi.org/10.1128/CMR.00089-17

MSN-FP6016 Assessment 1 Adverse Event or Near-Miss Analysis Scoring Guide

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
Analyze the missed steps or protocol deviations related to an adverse event or near miss. Does not list the missed steps or protocol deviations related to an adverse event or near miss. Lists the missed steps or protocol deviations related to an adverse event or near miss, but does not analyze how they led to the adverse event or near miss. Analyzes the missed steps or protocol deviations related to an adverse event or near miss. Analyzes the missed steps or protocol deviations related to an adverse event or near miss. Identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty where further information could improve the analysis.
Analyze the implications of the adverse event or near miss for all stakeholders. Does not list the implications of the adverse event or near miss for all stakeholders. Lists possible impacts of the adverse event or near miss for stakeholders, but does not analyze the short- or long-term implications. Analyzes the implications of the adverse event or near miss for all stakeholders. Analyzes the implications of the adverse event or near miss for all stakeholders. Identifies assumptions on which the analysis is based.
Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Does not list quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Lists quality improvement technologies related to the event that are required to reduce risk or increase patient safety, but does not evaluate how those technologies were used or could have been used more effectively. Evaluates quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Evaluates quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Identifies criteria by which to evaluate the technologies.
Incorporate relevant metrics of the adverse event or near-miss incident to support need for improvement. Does not identify relevant metrics of the adverse event or near-miss incident to support need for improvement. Attempts to identify metrics relevant to the adverse event or near-miss incident, but omits relevant data or does not show how metrics relate to the event or incident. Incorporates relevant metrics of the adverse event or near-miss incident to support need for improvement. Incorporates relevant metrics of the adverse event or near-miss incident to support need for improvement. Evaluates the quality of the data.
Outline an evidence-based quality improvement initiative to prevent an adverse event or near miss. Does not outline an evidence-based quality improvement initiative to prevent an adverse event or near miss. Attempts to outline a quality improvement initiative to prevent an adverse event or near miss, but it is not clear that all QI suggestions are evidence-based. Outlines an evidence-based quality improvement initiative to prevent an adverse event or near miss. Outlines an evidence-based quality improvement initiative to prevent an adverse event or near miss. Impartially considers conflicting data and other perspectives.
Communicate analysis and proposed initiative in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling. Does not communicate analysis and proposed initiative in a professional, effective manner; does not write clearly and logically with correct use of grammar, punctuation, and spelling. Attempts to communicate analysis and proposed initiative professionally and effectively but there are lapses, omissions, and/or errors that detract from the overall message. Communicates analysis and proposed initiative in a professional, effective manner, writing content clearly and logically, with correct use of grammar, punctuation, and spelling. Communicates analysis and proposed initiative in a professional, effective, and error-free manner, writing clearly and logically.
Integrate relevant sources to support arguments, correctly formatting citations and references using APA style. Does not integrate relevant sources to support arguments; does not correctly format citations and references using APA style. Sources lack relevance or are poorly integrated; citations or references are missing or not formatted according to APA style. Integrates relevant sources to support arguments, correctly formatting citations and references using APA style. Integrates relevant sources to support arguments, formatting citations and references, using APA style without errors.

Also read: NURS-FPX4900 Assessment 4 Patient Family or Population Health Problem Solution