ADVERSE EVENT OR NEAR-MISS ANALYSIS 1
Adverse Event or Near-Miss Analysis
Capella University
NURS-FPX6016 Quality Improvement of Interprofessional Care
June 28, 2021
, ADVERSE EVENT OR NEAR-MISS ANALYSIS 2
Adverse Event or Near-Miss Analysis
Introduction
The Centers for Disease Control and Prevention (CDC) report that one in four older
adults fall each year, and one in five falls cause serious injury (CDC, n.d.). The following is a
comprehensive review of an adverse event (AE) during this writer’s professional nursing career.
The scenario will be professionally analyzed, then evidence-based data will be applied to support
a quality improvement (QI) proposal aimed to decrease inpatient falls. For this analysis, the
hospital in which the AE occurs will is referred to as SRMC.
Analysis of an Adverse Event
Ms. Jones is a 72-year-old skilled nursing facility (SNF) patient who was found confused
and wandering. The pt was transported to SRMC emergency room (ER) to evaluate her sudden
change of condition. Recent medical history noted a total right hip surgery less than two weeks
prior and received rehabilitation therapy. Ms. Jones was diagnosed with severe sepsis and kidney
injury related to urinary tract infection. The pt was transported from the ER to the general
medical unit (GME) by a certified medical assistant (CNA). Upon arrival, the CNA received the
room assignment from the charge nurse and assisted Ms. Jones to her bed. The CNA had then
returned to the ER. Soon after her arrival, a code blue was initiated in another pt room. The nurse
for Ms. Jones was assisting in this event. Unfortunately, Ms. Jones had climbed over the side rail
and fell to the floor. The pt was tangled in the bedding and stated that her leg was hurting. After
examination and x-rays of the right hip, it was found that the hip was fractured and required
surgical intervention.
The fall that Ms. Jones suffered due to medical management rather than her underlying
condition of sepsis. Hospital protocol requires the nurse to complete a fall assessment upon
Adverse Event or Near-Miss Analysis
Capella University
NURS-FPX6016 Quality Improvement of Interprofessional Care
June 28, 2021
, ADVERSE EVENT OR NEAR-MISS ANALYSIS 2
Adverse Event or Near-Miss Analysis
Introduction
The Centers for Disease Control and Prevention (CDC) report that one in four older
adults fall each year, and one in five falls cause serious injury (CDC, n.d.). The following is a
comprehensive review of an adverse event (AE) during this writer’s professional nursing career.
The scenario will be professionally analyzed, then evidence-based data will be applied to support
a quality improvement (QI) proposal aimed to decrease inpatient falls. For this analysis, the
hospital in which the AE occurs will is referred to as SRMC.
Analysis of an Adverse Event
Ms. Jones is a 72-year-old skilled nursing facility (SNF) patient who was found confused
and wandering. The pt was transported to SRMC emergency room (ER) to evaluate her sudden
change of condition. Recent medical history noted a total right hip surgery less than two weeks
prior and received rehabilitation therapy. Ms. Jones was diagnosed with severe sepsis and kidney
injury related to urinary tract infection. The pt was transported from the ER to the general
medical unit (GME) by a certified medical assistant (CNA). Upon arrival, the CNA received the
room assignment from the charge nurse and assisted Ms. Jones to her bed. The CNA had then
returned to the ER. Soon after her arrival, a code blue was initiated in another pt room. The nurse
for Ms. Jones was assisting in this event. Unfortunately, Ms. Jones had climbed over the side rail
and fell to the floor. The pt was tangled in the bedding and stated that her leg was hurting. After
examination and x-rays of the right hip, it was found that the hip was fractured and required
surgical intervention.
The fall that Ms. Jones suffered due to medical management rather than her underlying
condition of sepsis. Hospital protocol requires the nurse to complete a fall assessment upon
