The goal of this assessment is to allow you to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a QI

Adverse Event Analysis 1

Adverse Event Analysis

Jonathan Fisher

School of Nursing and Health Sciences, Capella University

MSN-FP6016: Quality Improvement of Interprofessional Care

February 2021

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Adverse Event Analysis 2

Adverse Event Analysis

The purpose of this paper is to analyze an adverse event that occurred in the intensive care unit at

the hospital where I am currently employed. I will explain the event, analyze potential causes

and detail a quality improvement plan that was decided on to prevent similar events from

occurring in the future.

Description and Analysis of Event

The adverse event I will be analyzing is the development of multiple Hospital-acquired pressure

injuries on a patient who was admitted to the Intensive Care Unit with COVID. The patient was

initially admitted for respiratory distress related to COVID and quickly deteriorated and needed

to be intubated. The patient’s respiratory status continued to decline rapidly and the decision was

made to prone the patient. Due to the large number of COVID patients seen in this unit in the last

year, all the staff were familiar with and comfortable with best practices related to prone

positioning of patients. The patient was placed in the prone position for sixteen hours on 6

consecutive days before there was significant improvement in their respiratory status. One or two

days later it was noted in the electronic medical record that the patient had developed multiple

pressure injuries, including the chin, forehead, upper lip, and chest.

After the pressure injuries were noted, a review of the chart and a discussion with multiple

nurses who had cared for the patient revealed that the patient had not been consistently

repositioned while proned. While hospital protocol recommends repositioning every 2 hours,

including turning the head to the opposite head if possible, this was unable to be accomplished

consistently with this patient. There were multiple reasons in this case, including the patient’s

high acuity (the patient would easily desaturate with even minor movement), the patient’s size

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Adverse Event Analysis 3

and body habitus (the patient was obese and had a large, short neck which made head positioning

very difficult), and insufficient staffing related to the surge of COVID patients (there were shifts

when the nurse caring for this patient also had two other intubated COVID patients).

While the pressure injures were clearly related to prone positioning, they may also be considered

device-related pressure injuries. One was related to either the endotracheal tube or the tube

holder, and another was related to the positioning devices used to support the patient in the prone

position. Device related pressure injuries may at times be harder to prevent, especially in the

sickest patients, and they now account for more than thirty percent of all hospital-acquired

pressure injuries (The Joint Commision, 2018). While the hospital must take responsibility for all

pressure injuries it is a matter of debate as to whether all pressure injuries are truly preventable.

Pittman, (2019) argues that a pressure injury should be considered unavoidable if the patient was

at high risk and all prevention strategies were adequately used. While there were missed

opportunities in this case, the argument could be made that given the patient’s high risk they

were very likely to have pressure injuries related to prone positioning no matter what devices or

interventions were used.

Implications of Event

As hospital-acquired pressure injuries, whether device-related or not, are considered a measure

of the quality of the nursing care provided they are always treated as a significant event. In

addition, any adverse event has the possibility of having a significant effect on the patient and on

the patient’s ongoing care. While most adverse events have primarily short-term effects, up to

fourteen percent can have long-term effects such as permanent disability or eventual death

(Rafter, 2014). In addition to the patient, the family can also be affected by the adverse event,

especially if they perceive the event as having been caused by the healthcare team. While the

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Adverse Event Analysis 4

facility itself will be affected financially, the direct care providers can also be affected either in

the additional care that is required in promoting healing of the pressure injury or in the feelings

of guilt associated with thinking they should have done a better job of preventing the adverse

event.

Quality Improvement Technologies and Techniques

The initial approach to preventing the recurrence of pressure injuries related to prone positioning

was to remind staff to be as diligent as possible with repositioning these patients as much as is

safely possible. As lack of sufficient staffing was recognized as a significant factor, additional

staff from other departments were trained in assisting with repositioning proned patients and an

effort was made to increase the number of available staff on sections of the ICU with proned

patients. There was also discussion on whether the gel and foam positioning devices used were

the optimal available tools. Ultimately it was decided to reach out to vendors for samples of

similar positioning devices and trialing at least one new product. In addition, since on area of

injury was likely related either to the patient's endotracheal tube or the tube holder, a different

tube holder was chosen to be kept in stock on the unit as an option for staff to choose on proned

patients. At this point there was some concern that the different tube holder was likely to be less

secure and could potentially pose a problem in an increased risk of accidental extubation, so the

decision was made to take each patient on a case-by-case basis and let the primary nurse or the

charge nurse decide which device to use for each patient.

Related Metrics

While hospital acquired pressure injuries are a constant area of concern in intensive care units,

our ICU has been making them a point of focus for the last two or more years and has been

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Adverse Event Analysis 5

making significant improvements. On average we have one or two each month and over the last

six months our incidence is 1.3 per 1,000 patient days. This is only slightly above the average for

our entire hospital and is significantly better than other intensive care units across our hospital

system. Our trend over the last several years clearly shows that we are taking the necessary steps

to decrease our hospital acquired pressure injuries. This gives additional weight to the argument

that this particular incident and other recent adverse events are directly related to the current

surge of high acuity COVID patients. There are numerous anecdotal reports of a significant

increase in the incidence of hospital-acquired pressure injuries, as well as other hospital acquired

conditions as a result of the COVID pandemic. Perrilat (2020) mentions this and also opines that

the microvascular changes and thrombosis related to the COVID disease process may also be

increasing the risk of pressure injuries in these patients.

Quality Improvement Initiative

Our initiative to address hospital acquired pressure injuries in proned patients will take include a

number of approaches as there does not appear to be one specific cause of the event noted above.

First, we will emphasize the importance of pressure injury prevention and remind staff of the

progress we have made in the past when we focused on this issue. Next, we will continue to put

more emphasis on adequate staffing using this case as an example of some of the consequences

of inadequate staffing. We will also continue to reevaluate the devices we are using for

positioning our proned patients and will trial one or two new foam or gel devices. Due to how

common proned positioning has become during this pandemic, there is a recent increase in

literature related to prone positioning overall and related specifically to prevention of

complications that may result from prone positioning. While there is little in the way of direct

evidence of strategies that will decrease pressure injuries in COVID patients who are proned,

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Adverse Event Analysis 6

multiple organizations, vendors, and hospitals, along with these authors (Perrilat, 2020)

recommend using prophylactic dressings on all proned patients in an effort to mitigate risk.

There are numerous varieties of these dressings currently available as they have become more

common for prevention of heel and sacral pressure injuries in recent years. Many of these

dressings are available in a variety of sizes or can even be cut down to customized sizes and

shapes which makes it possible to use them on areas such the chin, cheeks, and forehead.

Conclusion

In conclusion, while there are numerous reasons why this particular patient was at very high risk

of developing pressure injuries, there are steps that we can take to decrease the risk in similar

patients in the future. Even though some pressure injuries may be considered unavoidable, they

should still be considered a serious event that we should do everything possible to prevent. There

is reason to believe that our incidence of pressure injuries will return to our baseline as our

number of COVID patients decreases so our interventions are focused on prevention specifically

in proned patients.

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Adverse Event Analysis 7

References

Barakat-Johnson, M., Carey, R., Coleman, K., Counter, K., Hocking, K., Leong, T., Levido, A., & Coyer, F. (2020). Pressure injury prevention for COVID-19 patients in a prone position. Wound Practice & Research, 28(2), 50–57. https://doi.org/10.33235/wpr.28.2.50-57

Perrillat, A., Foletti, J., Lacagne, A., Guyot, L., & Graillon, N. (2020). Facial pressure ulcers IN COVID-19 patients Undergoing prone Positioning: How to prevent an underestimated epidemic? Journal of Stomatology, Oral and Maxillofacial Surgery, 121(4), 442-444. doi:10.1016/j.jormas.2020.06.008

Pittman, J., Beeson, T., Dillon, J., Yang, Z., & Cuddigan, J. (2019). Hospital-acquired pressure injuries in critical and progressive care: Avoidable versus unavoidable. American Journal of Critical Care, 28(5), 338-350. doi:10.4037/ajcc2019264

Rafter, N., Hickey, A., Condell, S., Conroy, R., O'Connor, P., Vaughan, D., & Williams, D. (2014). Adverse events in healthcare: Learning from mistakes. QJM, 108(4), 273-277. doi:10.1093/qjmed/hcu145

The Joint Commission (2018). Managing medical device-related pressure injuries. Retrieved February 14, 2021, from https://www.jointcommission.org/resources/news-and- multimedia/newsletters/newsletters/quick-safety/quick-safety-43-managing-medical- devicerelated-pressure-injuries/

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Running head: ADVERSE EVENT ANALYSIS 1

Adverse Event or Near Miss Analysis

Capella University

Quality Improvement Interprofessional Care

Assessment 1

May 26, 2020

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ADVERSE EVENT ANALYSIS 2

Adverse Event or Near Miss Analysis

The missed steps or protocol deviations related to an adverse event or near-miss

To begin with, the adverse events and near-miss events are valuable learning occasions

and its evaluation aimed to improve the quality of patient care. One of the events that had

occurred and potentially could have caused irreversible consequences to the patient was an

undiagnosed hemorrhagic stroke. The patient with a history of injuries to the right side of their

body due to a car accident two years ago came to the emergency department. He reported fall at

home earlier in the morning. Upon arrival at the hospital's emergency department patient was

sent to the CT scan of his head but nothing remarkable was identified. The patient was admitted

due to complaints of right-sided weakness. Upon evaluation, there was a remarkable difference

in the patient's right upper extremity strength, range of motion, and noticeable weakness. Also,

the right lower extremity was weaker than the left. Due to the weekend and negative CT patient

‘s MRI scan was ordered as routine and was scheduled for the following day on Monday

morning. Meanwhile, nursing staff evaluated the patient every four hours using the NIH stroke

scale per admitting the doctor's order. The NIH score was 0 and the only deficits were weakness

and decreased range of motion recorded on the basic neuro assessment. Therefore, on Monday

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ADVERSE EVENT ANALYSIS 3

morning after the physician saw the patient their conclusion was to discharge the patient since

the patient have a pre-existing injury to the right side and there is no need to wait for the MRI but

if the nursing staff can try and expedite the MRI scan before discharge we can do it. Luckily for

the patient, the scan was done, and the radiology doctor called with the critical results – the

patient had an active hemorrhagic stroke. The discharge was canceled, and the patient was

provided with appropriate treatment.

This situation was based on the patient's medical history and not on a self-reported

change in condition and reliable test results. Doctors were quick to conclude that the reported

weakness and fall were related to the car accident two years ago and there is no need to follow a

healthcare organization protocol to rule out a stroke. This near-miss was prevented by following

standard steps and reliable diagnostic procedures. This event was reported to the charge nurse

that in turn informed the management. According to the data provided by the Joint Commission,

it is beneficial to report adverse or near-miss event since it helps in reducing risks of a similar

accident in the future, motivates the healthcare staff to implement initiatives for continuous

quality improvement performance, and simply alert the physicians to follow organization’s

protocols in order to promote harm mitigation (The Joint Commission, 2018).

The Implications of the Adverse Event or Near Miss for all Stakeholders

The short-term implications on the stakeholders are as followed:

– The patient and family – both were notified about the upcoming discharge and the

news about stroke was very unexpected. However, the patient was able to get the

appropriate medical care that reduced future harm.

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ADVERSE EVENT ANALYSIS 4

– The interprofessional team worked fast to provide the best patient care and ensure the

best patient outcomes. This included neurology consultation and follow up and

cardiology consultation due to the patient's uncontrolled hypertension.

The long-term implications can be more complex:

– The patient and family – according to the study of patients and their families who had

experienced near miss or adverse event performed by Ottosen and her team, had

found that long-term impact is very complex and harmful. “These effects unfold in

their homes, families, and communities, often long after they leave the hospital, and

can have huge individual and societal costs” Ottosen et al, 2018). In other words, the

realization of the potential harm affects individuals later in life and impact families

and patients psychologically, socially, and financially.

– The interprofessional team impact can be noticed in reflections and analysis of past

events. In other words, the involved healthcare team will answer the important

question "What can be done differently?" and self-reflection in the long-term can help

in preventing similar events.

The interprofessional team's responsibility and measures that should have been taken

include a review of policies and procedures and all the steps included in the ACLS guide related

to the stroke patient. In addition, the analysis will include evaluation of the particular case and

finding the reasoning to the fact that the patient's subjective feelings of weakness were not taken

seriously or basically ignored. An important change in the process of evaluation of the patient

with the rule out stroke will be avoiding any discharge until all the diagnostic tests are complete

to ensure the patient's safety and quality of care.

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ADVERSE EVENT ANALYSIS 5

Quality Improvement Technologies that are Required to Reduce Risk and Increase

Patient Safety

One of the quality improvement technologies that can help to reduce the risk of near-miss

events can be the utilization of the Electronic Medical Record. This form of technology can

promote patient safety. According to the research conducted by Waithera et al, there are five

significant advantages of the EMR. First of all, the record contains all the relevant information

which is patient specific. Secondly, by utilizing all the relevant information, healthcare

professionals can make an informed decision about patient care that includes recent laboratory

results, allergy history, and tests. The third benefit is related to healthcare provider order

management. New and even old prescription with specific doses and regimen are stored and

easily retrieved from the EMR. This advantage is an important milestone in reducing medication

administration errors and addresses an issue of polypharmacy. The fourth advantage is

addressing the quality of care improvement issues. Since EMR is a systematic and organized

platform, it allows better evaluation and analysis of patient-specific care which in turn helps in

identifying new health conditions and symptoms. The fifth benefit allows to "…facilitate

exchange of electronic information. EMR systems co-exist with other systems in the health care

system. These include other EMR systems, laboratory systems, and pharmacy systems” (2017, p.

2).

By appropriately utilizing the existing technology the interprofessional healthcare team

can make an informed decision about the patient's condition and improve the quality of patient

care. In addition, based on the patient's suspected diagnosis, the electronic medical record can

include a virtual checklist or build-in diagnostic tests that are required prior to the patient being

discharged. This checklist will follow the organization's standard protocols.

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ADVERSE EVENT ANALYSIS 6

Relevant Metrics of the Adverse Event or Near Miss Incident

The concept of harm prevention or simply not causing any harm to the patient has a long

history. The most known reports To Err is Human back in the 90s raised the public's attention to

this matter and healthcare organizations implemented various initiatives to evaluate and decrease

any human-caused medical errors. According to the Agency of Healthcare Research and Quality,

the most effective key performance indicators and metrics of the adverse events or near miss

based on near-miss report system. It is proven that developing an open and trusting relationship

between medical staff and management helps in preventing future mistakes and facilitates better

communication. Also, Wang & Yan in their case study describes the causation model and state

that adverse events and near misses forerunners to more serious medical errors (2019).

“Examining near misses provides two types of information relevant for patient safety: (1) that on

weaknesses in the health care system (errors and failures, as well as inadequate system defenses)

and (2) that on the strengths of the health care system (unplanned, informal recovery actions)

which compensate for those weaknesses on a daily basis, often making the essential difference

between harm and no harm to a patient “ (Wang & Yan, 2019). This information can be

generated from the healthcare facilities’ dashboard and helps with analysis and modifications of

the healthcare approach that ensures higher quality and safe patient care.

Quality Improvement Initiative to Prevent Future Adverse Event or Near Miss

Quality improvement is the ultimate goal of the healthcare organization. To better define

the improvement process, the report system of the near-miss event must be improved, and the

relevant data evaluated. This will allow better analysis and further understanding of the event

with future development of the steps to prevent a similar occurrence.

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ADVERSE EVENT ANALYSIS 7

The current protocol that is related to the patients with rule out stroke includes step by

step and time-sensitive patient ca

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