Adverse Events or Near Miss Analysis

Adverse Events or Near Miss Analysis

Healthcare professionals are responsible for safeguarding patient safety and providing quality care to enhance patient health and wellness. However, unanticipated events can compromise the quality of care and expose patients to detrimental consequences, including injuries, pain, and death. Liukka et al. (2020) define adverse events as “an unintended or unexpected incident which causes harm to a patient and may lead to temporary or permanent disability” (p. 2).

Examples of adverse events include diagnostic errors, surgical mistakes, hospital-acquired infections, and medication errors. Schwendimann et al. (2018) contend that these unanticipated events are the third leading cause of death in the United States and contribute to a massive economic burden. Other consequences of such incidences are hospital admissions.

Healthcare professionals are responsible for Implementing evidence-based interventions for detecting, responding to, and preventing adverse events. This paper reviews a case scenario of an adverse event, analyzes the missed steps in the case study, elaborates on the implications of adverse events on stakeholders, and recommends strategies for improving care quality.

An Overview of the Case Scenario

The reported case of an adverse event involved the nurse’s failure to adhere to one “right” of medication administration. A 65-year-old male patient reported to the hospital’s emergency department (ED) with chief complaints of blurred vision, general body weakness, confusion, dizziness, and fainting incidences.

Upon conducting clinical examinations, the on-floor physicians and nurses confirmed that the patient suffered from hypotension and needed urgent care. The physician tasked with case management ordered norepinephrine as a peripheral vasoconstrictor to stimulate the heart and dilate coronary arteries.

He wrote a prescription note indicating that the patient needed a 12mcg dose of the medication, which the nurse should administer intravenously. Also, the prescription note suggested a 2.4 mcg/min IV infusion as a maintenance dose.

During the medication administration process, the clinical nurse committed an error by failing to read the prescription note effectively. Consequently, he ended up administering 112mcg of norephedrine and 24mcg/min IV infusion as a maintenance dose. The patient responded adversely to the drug overdose by portraying various signs, including breathing problems and vomiting.

The bedside nurse tried to revert the consequences of norepinephrine overdose by the patient succumbed to the effects shortly after exhibiting various forms of distress. This case led to multiple ethical and legal implications, including suspension, regulatory scrutiny, a series of lawsuits, and a tarnished reputation of the hospital.

An Analysis of the Sequence of Events, Missed Steps, or Protocol Deviations

The error involving misinterpretation of the prescription note denotes various missed steps and protocol deviations, including ineffective communication mechanisms and the failure to interpret the physician’s handwriting. Firstly, communication chasms and gaps between the physician and the clinical nurse perpetuated the cognitive error.

Secondly, the nurse did not adhere to the requirement for double-checking medication labels and guidelines for administering high-alert medications. Thirdly, the scenario signifies failures in the reporting system, facilitated by bureaucracies and ineffective communication.

For instance, the nurse had the responsibility to notify other on-floor healthcare professionals, including physicians, regarding the errors to enhance response interventions and probably save the patient. Consequently, it is valid to contend that healthcare professionals could have prevented this incident by addressing individual and institutional risk factors for medication errors, including the individual inability to read and interpret the prescription note, communication breakdowns, and barriers to effective and timely incident reporting.

Implications of the Adverse Events on Stakeholders

In the context of adverse events that occur in healthcare systems, including medical errors, hospital-acquired infections, and surgical failures, their subsequent implications affect all healthcare stakeholders, including patients, family members, healthcare professionals, and the health organization.

According to Liukka et al. (2020), patients and family members bear the immediate and more detrimental consequences of adverse events since they are the first victims. In this sense, events like medication errors, hospital-acquired infections, and surgical failures result in direct harm to patients and other ramifications that significantly affect family members, including patient death and the increased costs of treating injuries resulting from these issues.

On the other hand, healthcare professionals represent the second victims since they experience emotional and physical distress, legal scrutiny, and regulatory consequences after the occurrence of an adverse event. Also, they suffer compassion dissatisfaction, grief, depression, and guilt (Ozeke et al., 2019).

Healthcare organizations are the “third victims” in the context of adverse events. They encounter negative reputations, incur the cost of preventing future incidents, and have long-term business difficulties emanating from tarnished reputations and public dissatisfaction (Liukka et al., 2020, p. 2).

When considering the effects of adverse events, it is valid to argue that every stakeholder in the healthcare system is responsible for implementing quality improvement initiatives and organizational-level interventions for safeguarding patient safety and reducing susceptibility to adverse events.

Evaluation of Quality Improvement (QI) Actions and Technologies Related to the Event

The hospital needs to incorporate various quality improvement interventions, including advanced technologies to prevent medication errors. According to Schwendimann et al. (2018), healthcare organizations can implement individual or bundled interventions for preventing adverse events, including using checklists in the operating room, hand hygiene adherence, medication reconciliation practices, and retrospective record reviews for accurate monitoring of in-hospital adverse events. These strategies require the incorporation of the widespread role of advanced technologies.

Technological enhancements relevant to the overarching objective of addressing the adverse event include hospital dashboards, e-prescribing systems, clinical decision support systems (CDSSs), and computerized provider order entry (CPOE).

Alvarado et al. (2021) argue that hospital dashboards use visualization techniques that ease the cognitive load and improve data comprehension. Healthcare institutions use dashboards to prevent adverse events since they have the potential to guide quality improvement initiatives, mobilize healthcare professionals to improve care, and display data that impact care quality (Twohig et al., 2019). These functions of hospital dashboards render them effective technological enhancements in safeguarding patient safety and improving care quality.

Similarly, healthcare organizations use computerized provider order entry (CPOE), clinical decision support systems, and e-prescribing systems to prevent adverse events like medication errors. Devin et al. (2020) argue that these technologies reduce mistakes in medication management processes, including medication prescription and administration.

In this sense, they automate medication management interventions, eliminate the need for handwritten prescription notes, and enable healthcare professionals to distinguish look-alike and high-risk medications. Consequently, the hospital should consider these technological options to prevent adverse events.

Relevant Metrics of the Adverse Event or Near Miss to Support Need for Improvement

The hospital should leverage key performance indicators (KPIs) as relevant improvement metrics for quality improvement. The hospital dashboard is an ideal platform for healthcare professionals to comprehend performance metrics and assess the institution’s interventions for preventing adverse events, including medication errors.

According to Twohig et al. (2019), dashboards display data to clinicians regarding various metrics, including cancer quality measures, reported incidences of chronic conditions, and the number of readmissions recorded within 30 days.

Other metrics relevant to adverse events and near misses are the length of stay, timeliness of discharges, improved patient outcomes, grant funding status consistent with the reduction of hospital readmissions, and staff participation in quality improvement initiatives (Twohig et al., 2019). The hospital should use these performance metrics to guide quality improvement initiatives and identify areas of improvement.

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

A quality improvement initiative for preventing and responding to adverse events should accommodate multiple interventions, including the incorporation of advanced technologies, enhancing healthcare professionals’ knowledge and awareness of adverse events, and addressing loopholes in communication and reporting systems.

According to Manias et al. (2020), healthcare organizations can prevent errors and other adverse events by improving communication and reporting systems, implementing prescriber education, encouraging pharmacist-led medication reconciliation, and incorporating the role of advanced technologies, including barcoding medication administration, e-prescribing, and computerized provider order entry (CPOE).

Although these measures are effective in promoting process efficiency and preventing adverse events, a comprehensive quality improvement framework is essential for enacting and sustaining change.

The PDSA (Plan-Do-Study-Act) model can enhance the implementation of quality improvement initiatives by enabling healthcare professionals to systematically initiate, implement, evaluate, and sustain change approaches. According to Chen et al. (2020), the planning stage entails defining the problem, establishing goals, and developing an action plan.

Secondly, the “doing” stage involves testing and piloting interventions, enacting the plan, and measuring baseline data. Thirdly, the “studying” phase entails evaluating the plan’s outcomes and consistency with the desired outcomes.

Finally, the “action” stage encompasses scaling up the initiative, modifying quality improvement interventions, and sustaining change to transform the institutional culture. These four stages enable healthcare organizations to track change, align interventions with missions, and justify the need for quality improvement.

Conclusion

Amidst the obligation to safeguard patient safety and well-being, adverse events like medication errors, surgical failures, and hospital-acquired infections pose significant challenges to care quality and patient safety. These events are preventable, yet their occurrence results in detrimental consequences, including deaths, injuries, readmissions, and increased care costs.

Equally, they inflict various implications on healthcare professionals and institutions, including psychological distress, tarnished reputations, financial losses, and legal scrutiny. Healthcare organizations can prevent adverse events by using dashboards metrics to guide quality improvement initiatives, educating healthcare professionals, improving communication effectiveness, developing timely and efficient reporting systems, and incorporating the widespread role of advanced technologies like e-prescribing systems, clinical decision support systems, bar coding medication administration, and electronic health records systems (EHRs).

Adverse Events or Near Miss Analysis References

• Alvarado, N., McVey, L., Elshehaly, M., Greenhalgh, J., Dowding, D., Ruddle, R., Gale, C., Mamas, M., Doherty, P., West, R., Feltbower, R., & Randell, R. (2021). Analysis of a web-based dashboard to support the use of national audit data in quality improvement: Realist evaluation. Journal of Medical Internet Research, 23(11). https://doi.org/10.2196/28854
• Devin, J., Cleary, B. J., & Cullinan, S. (2020). The impact of health information technology on prescribing errors in hospitals: A systematic review and behavior change technique analysis. Systematic Reviews, 9(1). https://doi.org/10.1186/s13643-020-01510-7
• Liukka, M., Steven, A., Vizcaya Moreno, M. F., Sara-aho, A. M., Khakurel, J., Pearson, P., Turunen, H., & Tella, S. (2020). Action after adverse events in healthcare: An integrative literature review. International Journal of Environmental Research and Public Health, 17(13), 1–16. https://doi.org/10.3390/ijerph17134717
• Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11, 1–29. https://doi.org/10.1177/2042098620968309
• Ozeke, O., Ozeke, V., Coskun, O., & Budakoglu, I. I. (2019). Second victims in health care: Current perspectives. Advances in Medical Education and Practice, 10, 593–603. https://doi.org/10.2147/amep.s185912
• Schwendimann, R., Blatter, C., Dhaini, S., Simon, M., & Ausserhofer, D. (2018). The occurrence, types, consequences and preventability of in-hospital adverse events – a scoping review. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-3335-z
• Twohig, P. A., Rivington, J. R., Gunzler, D., Daprano, J., & Margolius, D. (2019). Clinician dashboard views and improvement in preventative health outcome measures: A retrospective analysis. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4327-3

Adverse Event or Near Miss Analysis Instructions

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.

Additional Requirements

Your assessment should also meet the following requirements:

Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page or References section.

Number of references: Cite a minimum of three sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master\’s Program (MSN) Library Guide for guidance.

APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.

Analyze the implications of an adverse event or a near miss for all stakeholders.

Analyze the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis.

Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.

Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
Evaluate and identify quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.

Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.

Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Reference

National Quality Forum. (n.d.). NQF patient safety terms and definitions. http://www.qualityforum.org/Topics/Safety_Definitions.aspx

Comprehensive Analysis on a Near Miss or Adverse Nursing Event Sample 2

Healthcare institutions employ the best evidence-based practices, and thus practices are constantly changing. Quality improvement projects in institutions help improve practice and promote patient safety. However, errors due to various causes occur. These errors may be sentinel events, medical emergencies, mild adverse effects, or near misses.

The severity of these errors depends on the type of error and the impact on patients’ and healthcare providers’ health and safety. When they occur, they probe healthcare institutions to develop strategies to ensure such an event does not occur in the future. This paper analyzes an adverse nursing event (medication) error and proposes quality improvement projects to prevent the event’s occurrence in the future.

A 20-year lady was wheeled to the emergency department and diagnosed with hypokalemia. She was on diuretics due to her hypertensive condition. The doctor prescribed a 300mEq potassium intravenous infusion to run for five hours. The emergency department nurse, a newly deployed nurse from the medical ward, overlooked the flow rate and administered the drug bypassing the IV drug administration pump. She ran the infusion in one hour, exposing the patient to various hyperkalemia risks. The patient developed fatal arrhythmias and died shortly afterward.

Analysis of Missed Steps and Protocol deviations Related to Adverse

The emergency department records the highest rate of medication errors in the hospitals, and this department’s hasty nature, panic, and confusion contribute significantly to medication errors. Root cause analysis of errors and the development of quality improvement projects are thus integral in this department. Several missed steps may cause the sentinel event.

The doctor prescribed a higher drug flow rate (60mEq) than the allowed flow rates (20-40mEq), and the nurse did not realize the mistake (Vanholder et al., 2018). The nurse also failed to ensure all the rights of medication, further aggravating the situation. She ignored the right frequency. She also bypassed the IV drug infusion pump and administered the drug with a usual drop stand which is challenging to regulate the IV flow rate. She did not follow the institution’s protocol of administering IV potassium infusions with a medication companion using a drug infusion pump.

Contrary to the standard practice, the patient was not adequately monitored. Patients under potassium IV infusing require constant monitoring such as ECG, checking serum potassium levels, and vitals, especially blood pressure and pulse rates (Hunter & Bailey, 2018). A doctor prescribes ECG monitoring, and he did not specify it in this case. ECG monitoring would have effectively managed this patient, detected the arrhythmias, and allowed for patient management.

The results of the events show several deficits in the nurse’s knowledge. She lacks an understanding of potassium toxicity. She also lacks an understanding of the institution’s protocols on managing potassium infusion. Understanding these institutional protocols and management algorithms and those set by regulatory agencies such as the Agency for Healthcare Quality and Research is essential in helping avoid the occurrence of such events in the future. The incident was preventable if these regulatory stipulations were followed.

Effects of the Sentinel Event on the Various Stakeholder

Medication errors are undesirable and lead to various effects in other healthcare institutions. The first stakeholder to get affected is the patient. The patient did not have control over the event, and she suffered most of the consequences. The event, in this case, caused loss of patient life. The patient’s family suffered grief, psychological trauma, and healthcare costs associated with losing a loved one. In addition, they fear healthcare institutions which may affect how they perceive healthcare institutions, healthcare professionals, and their health-seeking behavior (Mannion & Daves, 2018).

The interprofessional team will suffer consequences resulting from the event. The interprofessional team is the perpetrator of the event. The interprofessional team did not collaborate in care such as follow-up and monitoring, and thus the errors were not discovered early enough to prevent the irreversible damage. An interprofessional team failed by allowing a newly deployed nurse to manage a patient without supervision.

Healthcare professionals suffer psychological trauma witnessing or getting involved in preventable errors that lead to sentinel events (Manias, 2018). The guilt affects the individuals’ performance. In addition, healthcare institutions may carry out disciplinary actions such as suspension and job losses. Patients or their families sometimes decide to sue the hospital for damages caused by these preventable errors. These lawsuits are often hefty, exposing them to high healthcare costs and sometimes imprisonment.

The organization is tasked with ensuring ethical responsibility by ensuring staff understands the organizational and regulatory requirements. The healthcare institution suffers a soiled reputation from such events. The institution has failed in orienting new nurses to the respective roles and the regulations affecting their practice in the various hospital departments (Manias et al., 2018).

Care delivery is different from department to department, and staff orientation is thus a prerequisite. The institution suffers from decreased patient influx from fear of recurrence of such an event. If the patient’s family decides to sue the hospital, the hospital may incur high costs from these lawsuits and also a further soiled reputation when these cases reach media houses.

All members have a role in the interprofessional to create a safety culture. The healthcare providers were expected to collaborate to ensure the care provided was conversant with practice (Manias, 2018). Patient follow-up is not an only-nurses role, and the doctor should have followed on the patient’s progress. In addition, the nurse leader should have oriented these nurses to nurses’ roles in the emergency department.

Orientation and socialization of nurses in new departments improve interprofessional consultation, improving quality care delivery and patent safety. Continuing education programs to enhance the nurses’ knowledge of handling patients in the emergency would have helped create a safety culture at the workplace (Mannion & Davies, 2018). The leader would have also assigned a nurse to supervise her and only allowed her to work independently after learning all emergency department protocols.

After the incident, the healthcare institution developed and emphasized ensuring the presence of a medication assistant before drug administration. Healthcare consultation spreads accountability to many healthcare providers and ensures errors are not overlooked. The policy increased the healthcare providers’ responsibility and prevented another sentinel event. Nurses discovered that they administer drugs without a companion are subject to disciplinary actions in the healthcare institution.

Evaluation of Quality Improvement Technologies

The Institute of Medicine (IOM) reports that medication errors cause mortality and morbidity, with 0.724% outpatient deaths and 0.125% inpatient deaths, with significant morbidities such as paralysis, organ failure, and mental health issues resulting from medication errors (Leape, 2021). Healthcare records are the basis for healthcare quality improvement projects. Quality records are the cornerstone for healthcare decision-making. Healthcare data analysis enables healthcare providers and leaders to determine areas for improvement and plan interventions to improve healthcare delivery and patient safety. Thus, quality healthcare data collection technologies are integral to quality improvement projects.

Computerized provider order entry (CPOE) and clinical decision support systems (CDSS) systems are the leading healthcare technology promoting patient safety. CPOE helps healthcare providers avoid legibility errors and missing links, while the CDSS is the most significant intelligence system that provides diagnosis and treatment-related information to a healthcare professional (Angela & Adisasmito, 2019). These systems have significantly helped reduce medication errors by pointing out incorrect dosages and frequencies and wrong medications for specific diagnoses. In the sentinel event, the CDSS system would have alerted the infusion rates of IV potassium infusion, preventing the perpetrated clinical error.

According to Mortimer et al. (2018), quality improvement projects are driven by specific objectives and goals used to measure improvement projects’ success. These goals and objectives can be prepared using computers and provide consistent and reliable data to evaluate the success of quality improvement projects. Computed data, visual dashboards are integral in determining the success of healthcare institutions.

ealthcare dashboards are prepared by hospitals and comply with the local, state, and federal agencies’ stipulations regarding managing various conditions (Pestana, Pereira, & Moro, 202). Institutions prepare dashboards as internal goals to measure internal achievement and progress towards promoting patient safety and quality care delivery. These dashboards also measure an institution’s success relative to the external regulations.

Dashboards help improve patient safety and improve healthcare services quality. Dashboards are applied in all hospital departments, and they give real-time information to clinicians on relevant department-specific categories. Coupled with CDSS systems, they guide professionals’ clinical decisions to ensure safe and quality healthcare delivery (Kunjan, Doebbeling, & Toscos, 2019). They also help clinicians stay focused on organizational goals, and they have been successful in promoting change interventions and enhancing their success. These dashboards follow a general design, but hospitals can alter these designs to meet their needs. The hospital, St. Claire Medical Center (SCMC), can develop specific dashboards to steer organizational goals achievement.

Relevant metrics for Quality Improvement

Dashboard metrics have service-specific key performance indicators. The key performance indicators for quality improvement projects on medication administration errors are based on patient-clinician interactions. They are basically process (clinician-centered) and outcome (patient-centered) key performance indicators (Topos, 2019). The data from electronic health records will provide formidable information on following set protocols and achieving desired patient health outcomes.

The Agency for Healthcare Research and Quality and the Institute for healthcare improvement is responsible for healthcare improvement projects. The AHRG controls quality improvement in various areas such as disease-specific management (heart disease and diabetes management measures), patient safety (patient falls and healthcare patient information safety), and disease prevention measures (children immunizations) (AHRQ, n.d.).

Through the Network for Patient Safety Databases (NPSD), AHRQ reports metrics specific to the emergency department, including blood and blood products errors, device or medical/surgical supply errors, and medication and other substance errors (AHQR 2021). The medication error-specific metrics focus on the type, cause, and severity of the medication errors. Some important key performance indicators by the AHRQ and NPSD include heart failure mortality and death rates in the low-mortality-diagnosis-related groups (AHRQ, 2021). Healthcare institutions can develop key performance indicators aligned with these regulations to ensure adherence and improve quality care delivery and patient safety.

The healthcare institution relevant metrics would include a) LASA related medication rates, b) medication errors death rates, c) death rates from uncomplicated diseases, d) average waiting time for patients to be seen, e) blood and blood product-related adverse effects in the ED, and f) medication near-miss error reports (Leape, 2021). The hospital can integrate healthcare technologies to improve patient safety. The CPOE, CDSS, and dashboard metrics integration provide a formidable tool for evaluating healthcare decisions, patient safety, and quality improvement.

Dashboards improve healthcare delivery and promote patient safety. They act as evaluation tools and a source of motivation to healthcare providers and healthcare institutions. According to Kunjan et al. (2019), dashboards support healthcare professionals in rational decision-making. According to Isazan, Ojo, and Sullivan (2020), dashboards provide formidable professional evaluation tools to help professionals measure their practice and perform personal improvement towards achieving organizational goals and objectives. In another study, dashboards increase staff morale and are a source of motivation to healthcare providers. According to Pestana, Pereira, and Moro (2020), dashboards increase professional accountability and responsibility, resulting in high-quality and safe patient care.

Quality Improvement Initiative for SCMC

Current best practices to prevent medication errors include using the IV drug pump. Healthcare technology controls drugs and avoids dosage, drug, and frequency errors. Other initiatives include bedside handing over patients using the ISBAR tool and the use of medication companions (Wolf, 2018). Handing-over patients at the bedside familiarize nurses with the patients under their care and prevent errors after forgetting or confusing patients and their medications. Another strategy implemented is medication companions. Medication companions help prevent errors such as information misinterpretation, reading errors, and detecting errors perpetrated by other healthcare providers.

Quality improved models include the Donobedian (structure, process, and outcome), PDSA (Plan, Do, Study, and Act) cycle, and the Six Sigma Models (Define, Measure, Analyze, Implement, and Control) (Goldman et al., 2021). These Six Sigma and PDSA cycle models outline related processes integral in ensuring the best evidence-based practices for the quality improvement project. The six sigma model is formidable in determining errors and their causes and planning evidence-based strategies to address these issues.

The PDSA cycle shortfall is its inability to determine causes and address cause-specific errors. The Baldrige criteria significant shortfall is inapplicability in clinical practice settings as it is more inclined to classroom settings (Menezes et al., 2018). LEAN thinking and Six Sigma models are somewhat similar but have variations in their explanation of the causes of errors; processes versus conduct errors (AHRQ, 2020). Quality improvement projects focus on techniques to improve care quality and patient safety, and hence, the Sigma model is the best in creating the outline for the improvement project (AHRQ, 2020). The model improves efficiency by providing a systematic approach that produces well-researched, analyzed, and evaluated data.

Quality improvement integrated initiatives involving multidisciplinary teams are the best to enhance healthcare improvements. An integrated CDSS, CPOE, dashboards program, and The Six Sigma model quality improvement strategy will significantly improve healthcare settings. The four components have had marked healthcare settings’ success, and their integration will lead to a superimposed increase in healthcare efficiency and reduced medication errors in all departments.

Conclusion

Healthcare QI projects are often tedious and involve a lot of data work. Data collection from the patient-healthcare provider interaction to an analysis of the data involves different healthcare technologies. Healthcare leaders must be willing to invest in the data analysis process to develop an effective evidence-based intervention to improve healthcare settings and ensure high-quality care and patient safety. Thus, healthcare leaders must ensure comprehensive data collection and analysis for quality decision-making. As seen above, integration of the Six Sigma model, Clinical provider order entry, and clinical decision support systems provide a quality improvement project outline.

Adverse Events or Near Miss Analysis References

• Agency for Healthcare Research and Quality (AHRQ) (2020). Section 4: Ways to Approach the Quality Improvement Process (Page 2 of 2). Retrieved 14^th January 2021, from https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/sect4part2.html
• Agency for Healthcare Research and Quality (AHRQ) (2021). Network for Patient Safety Databases. Medication or Other Substance Dashboard. Retrieved 14^th January 2021, from https://www.ahrq.gov/npsd/data/dashboard/medication.html
• Angela, N., & Adisasmito, W. B. B. (2019). Computerized Physician Order Entry (CPOE) in Reducing Medication Error: A Narrative Review. Jurnal Administrasi Rumah Sakit Indonesia, 5(3). http://dx.doi.org/10.7454/arsi.v5i3.3030
• Goldman, J., Smeraglio, A., Lo, L., Kuper, A., & Wong, B. M. (2021). Theory in quality improvement and patient safety education: A scoping review. Perspectives on medical education, 10(6), 319-326. https://doi.org/10.1007/s40037-021-00686-5
• Hunter, R. W., & Bailey, M. A. (2019). Hyperkalemia: pathophysiology, risk factors, and consequences. Nephrology Dialysis Transplantation, 34(Supplement_3), iii2-iii11. https://doi.org/10.1093/ndt/gfz206
• Isazad, M. M., Ojo, A., & Sullivan, F. J. (2020, January). Investigating Analytics Dashboards’ Support for the Value-based Healthcare Delivery Model. In Proceedings of the 53rd Hawaii International Conference on System Sciences. https://doi.org/10.1145/3335082.3335109
• Kunjan, K., Doebbeling, B., & Toscos, T. (2019). Dashboards to support operational decision making in health centers: a case for role-specific design. International Journal of Human-Computer Interaction, 35(9), 742-750. https://doi.org/10.1080/10447318.2018.1488418
• Leape L. L., (2021). We Can Do This: The Institute for Healthcare Improvement Adverse Drug Events Collaborative. In: Making Healthcare Safe. Springer, Cham. https://doi.org/10.1007/978-3-030-71123-8_6
• Manias, E. (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert Opinion On Drug Safety, 17(3), 259-275. https://doi.org/10.1080/14740338.2018.1424830
• Mannion, R., & Davies, H. (2018). Understanding organizational culture for healthcare quality improvement. BMJ, 363. https://doi.org/10.1136/bmj.k4907
• Menezes, P. H. B., Martins, H. C., & Oliveira, R. R. (2018). The excellence Baldrige criteria in the effectiveness of higher education institutions management. BBR. Brazilian Business Review, 15, 47-67. https://doi.org/10.15728/bbr.2018.15.1.4
• Mortimer, F., Isherwood, J., Wilkinson, A., & Vaux, E. (2018). Sustainability in quality improvement: redefining value. Future Healthcare Journal, 5(2), 88. https://dx.doi.org/10.7861/futurehosp.5-2-88
• Pestana, M., Pereira, R., & Moro, S. (2020). Improving health care management in hospitals through a productivity dashboard. Journal of Medical Systems, 44(4), 1-19. https://doi.org/10.1007/s10916-020-01546-1
• Vanholder, R., Van Biesen, W., & Nagler, E. V. (2018). Treating potassium disturbances: kill the killers but avoid overkill. Acta Clinica Belgica. https://doi.org/10.1080/17843286.2018.1531206
• Wolf, Z. R. (2018). Strategies to reduce patient harm from infusion-associated medication errors: a scoping review. Journal of Infusion Nursing, 41(1), 58-65.

Also read: NURS FP6016 SimmonsC Assessment 1 Adverse Event or Near Miss Analysis