Prepare an analysis (5-7) pages of an adverse event or a near miss event from your professional nursing experience and outline a QI initiative that would address it.
Patient Evelyn, aged 68, underwent a knee replacement surgery at the hospital aiming
at alleviating years of pain and enhancing her movement. After the surgery was successfully
done, she was sent over to the orthopedic recovery ward for post-op care. Along with the
visits of her surgeon, administration of drugs by nursing staff and tests for vital signs,
Evelyn's recovery improved gradually.
Nevertheless, on a particular evening shift, Nurse Jessica was shocked by a loud thud.
Trying to find out the cause, the nurse saw Evelyn lying on the floor after she had fallen out
of bed. The medical staff reacted promptly, supporting Evelyn and implementing the
emergency procedures. Based on the feedback, the incident highlighted gaps in the safety
measures—unfastened bed rails, unmonitored bed elevation, and loose wheels.
After the accident, Evelyn's family called for a review of the hospital protocols, which
were acted upon immediately. This incident resulted in a reassessment of patient safety
mechanisms and a decision to implement quality improvement efforts. In turn, the
administrative staff and leadership in the hospital were determined to learn from this
experience, implement any required changes, and ensure the safety of all patients under their
care.
The Implications Of The Near Miss Event For All Stakeholders
The near-miss incident of Evelyn’s falling from her bed involved various people and
stakeholders. First of all, for Evelyn and her family, the event could result in their feeling fear
and anxiety and losing trust in the ability of the hospital to render safe care. The physical
harm Evelyn suffered could lead to the deterioration of the treatment process; hence, the
family imposed legal duties on the hospital, and demanded accountability. Besides, they may
also have been under emotional pressure and a feeling of disloyalty, hence the need for the
hospital to give the assurance of transparency.
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