NURS FPX 6016 Assessment 2 Guiding Questions
Guiding Questions
Adverse Event or Near Miss Analysis
This document is designed to give you questions to consider and additional guidance to help
you successfully complete the Adverse Event or Near Miss Analysis assessment. You may find
it useful to use this document as a prewriting exercise, an outlining tool, or a final check to
ensure you have sufficiently addressed all the grading criteria for this assessment. This
document is a resource to help you complete the assessment. Do not turn in this document as
your assessment submission.
For examples of adverse events or near misses, visit:
Agency for Healthcare Research and Quality. (2021). WebM&M cases & commentaries.
https://psnet.ahrq.gov/webmm
Analyze the implications of the adverse event or near miss for all stakeholders.
● What are the possible short-term and long-term effects on the stakeholders (patient,
family, interprofessional team, facility, community, et cetera)?
● What are the responsibilities and actions of the interprofessional team related to the
adverse event or near miss?
● What measures should have been taken? Who are the responsible parties or roles?
● How did the incident impact the stakeholders? Did it change how they do their work, or
how or what they report?
Analyze the sequence of events, missed steps, or protocol deviations related to the
adverse event or near miss using a root cause analysis.
● How did the event result from a patient's medical management rather than from the
underlying condition?
● What were the missed steps or protocol deviations that led to the adverse event or near
miss? What was overlooked? Why?
● What kind of interprofessional communications could have prevented this event?
● To what extent was the adverse event or near miss preventable?
Evaluate quality improvement actions or technologies related to the event that are
required to reduce risk and increase patient safety.
2
● What quality improvement technologies are in place to increase patient safety and
reduce risks that pertain to this adverse event? What would prevent it from happening in
the future?
● Are those technologies being utilized appropriately? How could they be more usefully
employed?
● How do other institutions prevent these types of events from occurring?
● What data are generated from the facility’s dashboard related to the selected incident?
(By dashboard, we mean the data that are generated from the information technology
platform that provides integrated operational, financial, clinical, and patient safety data
for health care management. This is not something you will find online or in the Capella
library.)
● What data are associated with the adverse event or near miss? What do the relevant
metrics show? (Patient satisfaction and readmission rates are important metrics. Look at
trending data and compare to see where relevant metrics are headed.)
● What research or data related to the adverse event or near miss is available outside of
your institution?
● Compare internal data to external data. What do you find?
Outline a quality improvement initiative to prevent a future adverse event or near miss
based on research and evidence-based practices.
● How was the incident managed and monitored in the selected institution?
● What quality improvement initiatives have been shown to work? Why are they
successful? What is the evidence?
● What elements can be applied to prevent future adverse events or near misses?
Convey purpose, in an appropriate tone and style, incorporating supporting evidence
and adhering to organizational, professional, and scholarly writing standards.
● Is your analysis logically structured?
● Is your analysis 5–7 double-spaced pages (not including title page and reference list)?
● Is your writing clear and free from errors?
● Does your analysis include both a title page and reference list?
● Did you use a minimum of three sources? Were they published within the last five
years?
3
● Are they cited in current APA format throughout the plan?
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