NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

Adverse Event or Near-Miss Analysis

Student name 

Capella University

NURS FPX6016

Professor’s Name

Submission Date

Introduction

Near-miss analysis and reporting of adverse events are healthcare processes that help healthcare facilities ensure the safety of patients and ensure that the quality of care offered by the facility is safer. An adverse event is an event that causes a direct patient injury, but a near-miss is a phenomenon that is susceptible to causing patient harm but is avoided due to timely intervention (Agency for Healthcare Research and Quality, 2024). Both aid in risk factor identification, root cause analysis, and the development of preventive action plans through the provision of essential data.

To help healthcare systems advance their safety cultures and transform patient outcomes, a mechanism of carrying out systematic reviews of near-miss events alongside adverse event reports can be established. The subsequent evaluation reports about the incidence of a poor event in a 65-year-old female who acquired pressure ulcers due to spending a lengthy duration of time in immobility post-surgery. One of the quality improvement projects is addressed so as to avoid the same incident in the future.

Case Scenario

A life-threatening and unfavorable incident in Green Valley Regional Hospital’s intensive care unit (ICU) occurred when a postoperative cardiovascular patient developed a stage IV pressure ulcer due to immobility. Nursing staff had to constantly pack and unpack the patient and perform a skin evaluation. The patient, however, had to wait longer to be attended to by the provider as a result of high acuity and staffing shortages. Later, the patient acquired a very painful sacral ulcer and had more risks to infect and stayed longer in the hospital than would have been the case had the pressure ulcer been diagnosed and treated at an earlier stage.

Incident investigation through root cause analysis found that the problem was due to a lack of proper staffing, a lack of communication among the staff, and a lack of adherence to the established protocols in the prevention of pressure ulcers. Since that time, the hospital has established real-time risk tracking, higher staffing during times of high patient care demand, and strengthened staff education to improve adherence of the staff to the set protocols and eliminate such cases in the future.

Impact and Analysis of Near Miss

The incident at the Green Valley Regional Hospital that occurred at a bad time had a lot of different parties involved. It caused the patient to have increased pain and a higher risk of infection, caused emotional distress and delays in recovery time, which all led to decreased quality of life. Moreover, the family of the patient might have experienced anxiety and dissatisfaction with the treatment given to their loved one, and could have developed distrust towards the healthcare system (McQueen et al., 2022). To the nurses and other direct care employees, the incident can lead to moral distress, loss of job satisfaction, and potential issues related to their professional responsibility.

Moreover, the case shows that workload and staffing challenges of one facility can also impact the quality of care (Orgambidez et al., 2025). On an organizational scale, the hospital will most likely suffer in terms of reputational damage, an upsurge in the cost of healthcare, a possible source of lawsuits against the facility, and inspection by the relevant authorities (Skelly et al., 2023). Also, facility-level management should concentrate on system-wide flaws associated with the staffing configuration, interaction among staff, and following hospital-wide standards. Moreover, the payers will be faced with high expenses as the stay will be longer. On the whole, this event proves that the improvement of systems on a high level is an urgent step that should be taken to enhance patient safety, staff support, and design a high-quality outcome.

Assumptions

The analysis of the adverse event at the Green Valley Regional Hospital is based on various assumptions. To begin, a validated risk assessment instrument, like the Braden Scale, was used to assign the patient to the high-risk group of developing a pressure injury (Kennerly et al., 2022). Second, it presumes that orders to adhere to inpatient or outpatient routine prevention measures, such as regular repositioning and skin checks, have been introduced. Third, it presumes nurses to have missed nursing care due to staffing problems and due to an extra patient load.

Fourth, communication between and within shifts and members of the interprofessional team is broken, which probably had an impact on continuity of care (Atinga et al., 2024). Fifth, evidence-based practice (EBP) guidelines would have implied that the ulcer would not have taken place. Finally, it is presumed that there were proper documentation systems and reporting mechanisms, which were not used regularly or adequately.

Root Cause Analysis of the Sequence of Events

The pressure ulcer adverse event in the ICU of the Green Valley Regional Hospital chiefly occurred as a result of the systemic flaws in the care provision and not the cardiovascular condition and surgery of the patient. They would have expected the patient to be immobilized after surgery, but even the preventive measures that could have been provided to prevent complications like skin assessments, regular repositioning of the patient, monitoring of risks, etc., had not been practiced consistently. Patient acuity, poor staffing, and failure to communicate on a shift-to-shift basis worsened the timely use of the right preventatives to prevent pressure injuries.

In general, patient harm due to adverse events is usually interpreted as a consequence of system-level failures in healthcare delivery, not in relation to the underlying condition of the patient or any intentional patient harm by the healthcare providers (Kumah, 2025). The analysis to examine the factors transmitting pressure ulcers indicated that stricter workloads among the healthcare workers, ineffective communication among the team members, and system malfunction have triggered the majority of hospital-acquired pressure ulcers (Alanazi et al., 2023). These incidents necessitate systemic protocols in care to be formulated in such a manner that an adequate number of caregivers in these hospitals are sufficient and efficient communication channels between a caregiver and another caregiver in case there is a shift change among the staff in the hospitals.

Missed Steps and Protocol Deviations

A four-year-old high-risk post-operative patient in the ICU at Green Valley Regional Hospital acquired a stage IV pressure ulcer as a result of a failure to consistently implement pressure injury prevention measures. The patient was also diagnosed with immobility and had a risk of a pressure ulcer, but no consistent reviews of the skin and repositioning, documentation in the electronic health record (EHR), and handover during shifts were done, and communication-related problems with skin integrity and patient care emerged. The workload and shortage of staff affected nursing care and reduced their effectiveness in adhering to prevention measures.

To improve the reliability of care provided and ultimately decrease hospital-acquired pressure injuries that are preventable, evidence-based practice recommendations are to maintain standardized turning schedules, continuous risk assessments, and use of situation, background, assessment, and recommendation (SBAR) communication (Shrivastava et al., 2025). Comprehensively, this case emphasizes the necessity to have more robust system-level protection and adherent practices based on evidence to avoid needless harm and enhance patient safety.

Preventive Interprofessional Communications

In an attempt to curb the development of a stage IV pressure injury in ICU patients of Green Valley Regional Hospital, there should be increased interprofessional cooperation and formal communication between nurses, physicians, and specialists. The entire healthcare team would then have received all aspects of the patient care by handing over the entire patient care information to the complete team by utilizing interprofessional handoff SBAR during the shift change to support the safety of handover (Shrivastava et al., 2025). Also, regular multidisciplinary rounds involving physicians, nurses, and wound care specialists would enhance accountability and offer prompt interventions to the interdisciplinary team to ensure that the patient is not exposed to pressure injuries.

The studies show that the incidence of missed nursing care and patient safety problems is low in cases of organized communication and interprofessional collaboration (Putra et al., 2025). Also, turnover reports would be encouraged by introducing electronic, real-time documentation of turning schedules and electronic reminders, which will create continuity in care between shifts. It is necessary to develop more robust interprofessional collaboration among the care team to find gaps in care and avoid any unnecessary hospital-acquired pressure injuries in critically ill patients.

Preventability and Knowledge Gaps

The compliance of the staff members with the pressure injury prevention procedures was not consistent at the Green Valley Regional Hospital ICU. The documents received showed that the staff were not aware of much of their contribution in the turning process. Moreover, they also found that frequent handover communication errors were present, and the continuity of care was missed, which was a direct cause of the patient’s pressure injury.

Research studies back the idea that most hospital-acquired pressure injuries can be traced back to failure in communication and non-conformity to the protocols that underlie pressure injuries (Atinga et al., 2024). Besides this, studies show that there is a high incompleteness in the recording of the turning schedules and whether the early indicator of skin breakdown was escalated accordingly. Hence, it is essential that constant monitoring, employee training, and quality enhancement measures take place across the boundaries of the system.

Quality Improvements for Risk Reduction

The strategies and technologies of quality improvement (QI) play a vital role in the prevention of pressure injuries that are normally hospital-acquired, like the stage IV ulcer to which the individual was exposed. To implement the use of QI tools in preventing hospital-acquired pressure injuries, the utilization of EHR tools to provide risk assessment by the Braden Scale is being utilized (Kennerly et al., 2022). Additionally, using care bundles to prevent pressure injuries, as well as using repositioning reminders that are automated to ensure appropriate timing of skin assessments via clinical decision support systems, are also helpful (Chaboyer et al., 2024).

As soon as these tools are used regularly and properly, they will not only help the staff to detect high-risk patients in time, but also aid in the regular use of turning schedules and preventive measures. The problem, however, is that when not met in real-time, documentation inconsistencies, alert fatigue, and excessive workloads may contribute to a lack of effectiveness and decreased compliance.

Some institutions are complementing their prevention programs with multidisciplinary wound care teams, hourly rounding processes, pressure-sensing intelligent beds, and real-time audit dashboards, which measure and present the effective prevalence of compliance with pressure injuries and repositioning. Such programs motivate higher degrees of responsibility, decisive risk assessment, and observance of evidence-based care bundles. The significance of cost-effective facility dashboard data elements includes pressure injury incidence rate, repositioning and nursing documentation completion rates, length of stay (LOS), and hospital-acquired condition (HAC) scores.

Pressure injury incidence rates were observed to be associated with longer length of stay and decreased level of patient satisfaction; thus, their higher rates will also raise the count of contracted in-hospital infections (Alanazi et al., 2023). Exposure to bundle compliance data in hospitals indicates that hospital rates that are above 2-3 pressure injuries per 1,000 patient days indicate high compliance, and lower compliance has higher rates than those benchmarks. Through the comparisons of the internal benchmarks to the external benchmarks, the facility will be in a position to know areas that are not adhering to procedures, and will justify the necessity of more effective quality improvement activities and ongoing improvement audit systems.

Quality Improvement Initiative to Prevent Future Near Misses

Following the stage IV pressure ulcer incident at the ICU in the Green Valley Regional Hospital, interventions made were: urgent consultation on wound care, immediate escalation to the unit leader, and initiating a root cause analysis to diagnose system malfunctions contributing to the incident. Examples of monitoring were analysis of nursing records, staffing ratio analysis, adherence to repositioning measures, and patient outcome measures. The results showed lapses in the observance of prevention practices, miscommunication in case of a patient hand-off, and lack of care in situations with overworking.

Evidence-based QI programs aim at minimizing hospital-acquired pressure injuries by ensuring regular application of standardized pressure injury prevention bundles, use of e-Braden Scale-amineable alerts, organized rotation schedules, and multidisciplinary wound care teams. It has been proven that bundles prove to be effective as they combine a number of interventions into one solution and will be more reliable in delivering care across the shifts (Chaboyer et al., 2024).

There is further evidence that hourly rounding and real-time EHR reminders also have had a large impact on reducing the occurrence of pressure injuries by enhancing accountability and early intervention (Gliner et al., 2022). Using Lean principles, introducing frequent auditing and feedback loops, and conducting interprofessional rounds will help increase compliance. Continuous training of the staff and leadership control are also important to preserve compliance and increase patient safety.

Conclusion

The incident that has caused a stage IV pressure ulcer can be considered evidence of how system-level failure, attributable not only to insufficient staffing but also to the failure of communication and only minimal compliance with prevention measures, jeopardizes the safety of patients. The analysis revealed that most adverse events are caused by a set of features; in particular, the human factor, the organizational factor, and the process factor. Facilities must enhance interprofessional collaboration between providers, develop and implement common evidence-based prevention techniques for pressure injuries, as well as utilize health information technology to reduce the risk of such events.

Next Assessment: NURS FPX 6016 Assessment 2