Adverse Event and Near-miss analysis

1

Adverse Event or Near-Miss Analysis

Capella University

FPX6016: Quality Improvement Interprofessional Care

Dr. Michelle Dykes

June 16, 2021

2

Adverse Event or Near-Miss Analysis

Delivery of quality healthcare builds a critical assessment of specific approaches that

build change and help influence change and improve individual needs. According to Saluja and

Bryant (2021), approximately 67% of pregnancy-related deaths in the United States are

preventable. The quality of care and recognizing essential maternal warning signs are essential

in saving the lives of women (Saluja & Bryant, 2021). Since because black women are three

times more likely than Caucasian women to die, a detailed review of the underlying inequities

in healthcare delivery is required. Globally, maternal mortality has dropped by roughly 2.9

percent. However, in the United States, the tendency has been the polar opposite, with an

estimated 42 maternal fatalities per 100,000 (Amankwaa et al., 2018). Understanding this

pattern emphasizes the need for more favorable policies and regulations to aid in developing a

stronger forum for advancement by focusing on black women.

Pregnancy-related deaths are five times as common in black women over 30 than in

white women. In states with a low pregnancy-related mortality ratio, the mortality rate was

similarly high (PRMR) (Collier & Molina, 2019). These findings show that the existing

disparity in pregnancy-related fatality rates among black and white women is a sensitive and

complex national issue. Because these are avoidable diseases, delivering high-quality maternity

care will greatly reduce the mortality rate linked with them (Chinn et al., 2020).

Case scenario

A 30 years old was brought into the emergency department at Safe Care Health Clinic

with heavy bleeding, severe back pain, fever that had lasted for more than 24 hours and foul-

smelling vaginal discharge. Upon further clinical examination, it was found that she had an

unsafe abortion, and some of the fetus parts had remained in the body, which was contributing

to severe discomfort. However, no scan was performed to ascertain the extent of the problem.

3

Further, the doctor did not inquire about the period taken since the unsafe abortion was

conducted. The patient was given intravenous fluid for volume replacement and antibiotics and

discharged the following day after the pain had reduced immensely. There was no vacuum

aspiration indicated despite the realization that the woman had attempted to procure an

abortion. However, after three weeks, she came back with more intense pain and was diagnosed

with endometriosis. The solution was to perform a hysterectomy, which would have been easily

prevented had the correct decisions been made in the initial incidence considering the urgency

and the likelihood of adverse outcomes.

The incident, as observed, shows a series of medical errors made by admitting

physicians, and they could have been easily prevented had the management protocol been

followed efficiently. Building a broader basis for change and improved consideration of the

patient's healthcare needs should inform the decision to management approach adopted

(Macdorman & Declercq, 2018). Thus, the analysis will provide a detailed evaluation of all the

errors that would have been avoided to ensure that the patient received total quality care. The

assessment will also incorporate the implication of the adverse event on the stakeholders

involved in the whole process.

Analysis of the missed steps to the adverse event

Management of care within a hospital context is evaluated based on the severity of the

patient and the underlying risks that are likely to arise based on given standard operating

procedures. All healthcare providers are expected to adhere to standard operating procedures in

managing patients to ensure that there are no errors within the healthcare environment. The

patient who came to the facility had major signs indicating that she had complications from

unsafe abortion (Miller & Leffert, 2020). The doctor would have known the severity of the

situation and opted to conduct a detailed physical assessment to protect the patient's healthcare

4

needs. It is imperative to fully review the patient's situation before determining the type of

management approach.

One of the symptoms that the patient exhibited included foul-smelling vaginal

discharge. This is a key indication that there are some retained parts resulting from unsafe

abortion that was conducted. However, the doctor bypassed this important sign and opted to

prescribe medication to treat other symptoms that the patient was having. Despite knowledge of

the unsafe abortion, the doctor also failed to investigate the length until the symptoms began to

show. The period in this context would have been essential in determining the extent of internal

damage and determine whether it was prudent to conduct vacuum aspiration to clean the uterus.

These challenges can stem from varied sources, including a lack of communication and

delivery of healthcare as a multidisciplinary practice. It is essential to focus on building a

broader change approach that defines an improved basis for change and an improved level of

focus. Building a higher level of engagement within a given context illustrate the need and

ability to improve efficiency and change development strategy (Purohit, 2021). A

multidisciplinary approach to care means an interactive process where all healthcare providers

deliver quality care jointly.

The implication of the adverse event on the stakeholders

The underlying concern based on the whole situation is lack of communication and the

basis of ideology sharing. It would be significant to build change and promote a broader basis

for change development. The adverse event laid a claim on the ability to provide quality care

by the hospital. The patient is the victim of the adverse event, which can be treated as

negligence by the healthcare provider. Healthcare providers are required to provide quality and

ethical care where the patient's needs and well-being serve as the priority of the care approach

5

considered. The actions of the doctor should focus on promoting the general good rather than

harm the patient.

As a key stakeholder in this context, the hospital suffers immensely from low ratings

and claims of incompetency from patients aggrieved by the manner they were treated.

Credibility in a healthcare context is integral to the success of any approaches that are being

integrated within a given care environment. Building a strong change platform defines an

improved change approach where it is possible to understand change strategies and different

measures that build a broader basis of development.

Quality improvement technologies

Improving the quality of care in this context presents a broader basis within which it is

possible to achieve a greater level of change within a hospital setting. Thus, a quality

improvement measure that would be significant in this context is introducing imaging

technologies as standard procedures for patients with severe symptoms to have a better visual

knowledge of the source of discomfort and change development strategy (Mehta et al., 2016).

Health information systems would also be integral in improving the quality of care since the

system would send prompts to questions regarding patient history that have not been asked to

ensure that it is filled and inform on the care development process. Health information

management systems have been integral in building a strong and medical error-free practice

(Willcox et al., 2020).

Relevant Metrics of Quality Improvement for Safe Care Health Clinic

Assessing metrics in the care environment provides a basis for identifying whether the

quality of care delivered is sufficient. The efficiency of these projects presents a broader

context for change and the adoption of better measures that build change and adopt an

improved performance level. The key metrics that are assessed in this context involve checking

6

and documenting patient vital signs. The care providers should be competent and can build a

broader basis for change and the adoption of changing processes that improve efficiency and

change development (Macdorman & Declercq, 2018). Thus, assessment of their knowledge

levels and abilities is crucial in shaping change and the adoption of better systems that seek to

promote change and empower quality performance within a healthcare context. Patient

feedback is an essential metric that provides knowledge on how patients perceive the facility's

quality of care.

Outline for quality improvement initiative at Safe care Health Clinic

Improving healthcare quality presents a highly imperative basis within which it is

possible to achieve high-quality care. Building a strong change approach defines a broader

basis for change while also improving the quality of care. Therefore, Safe Care Health clinic

needs to integrate better approaches to help build change development strategy within the

healthcare environment (Dukhanin et al., 2018).

A Lean quality of care model is efficient in this context, considering that it presents a

strong basis for change and overall focus on quality rather than quantity. Healthcare providers

within the healthcare facility must be well trained and exhibit high-performance strategies. The

lean quality model aims at identifying the source of the problem and allows the development of

strategies and processes that can help control the quality of care (Amran et al., 2020). Thus,

these concepts should form the basis for the delivery of improved care and commitment to

change.

7

Conclusion

Integration of technology in the care context presents a strong basis for change where it

would be possible to influence change and help attain a high quality of care. The presence of

preventable adverse events within a care setting shows a lack of commitment to patient needs

hence negatively influence the quality of care approach. Quality improvement technologies that

could be employed in managing the patient situation to overcome an adverse outcome have

also been effectively investigated and present a broader basis for a higher level of change in

terms of quality of care delivery.

8

References

Amankwaa, L. C., Records, K., Kenner, C., Roux, G., Stone, S. E., & Walker, D. S. (2018).

African-American mothers’ persistent excessive maternal death rates. Nursing Outlook,

66(3), 316–318. https://doi.org/10.1016/j.outlook.2018.03.006

Amran, M. D. M., Januddi, F., Nuraina, S., Ikbar, A. W. M., & Khairanum, S. (2020). The

barriers in lean healthcare implementation. Test Engineering and Management.

Chinn, J. J., Eisenberg, E., Artis Dickerson, S., King, R. B., Chakhtoura, N., Lim, I. A. L.,

Grantz, K. L., Lamar, C., & Bianchi, D. W. (2020). Maternal mortality in the United

States: research gaps, opportunities, and priorities. American Journal of Obstetrics and

Gynecology. https://doi.org/10.1016/j.ajog.2020.07.021

Collier, A. R. Y., & Molina, R. L. (2019). Maternal mortality in the united states: Updates on

trends, causes, and solutions. NeoReviews. https://doi.org/10.1542/neo.20-10-e561

Dukhanin, V., Topazian, R., & Decamp, M. (2018). Metrics and evaluation tools for patient

engagement in healthcare organization-and system-level decision-making: A systematic

review. In International Journal of Health Policy and Management.

https://doi.org/10.15171/ijhpm.2018.43

Macdorman, M. F., & Declercq, E. (2018). The Failure of United States Maternal Mortality

Reporting and Its Impact on Women’s Lives. In Obstetrical and Gynecological Survey.

https://doi.org/10.1097/OGX.0000000000000617

Mehta, R., Bhatt, N., & Ganatra, A. (2016). A Survey on Data Mining Technologies for

Decision Support System of Maternal Care Domain. International Journal of Computer

Applications. https://doi.org/10.5120/ijca2016908965

Miller, E. C., & Leffert, L. (2020). Stroke in Pregnancy: A Focused Update. Anesthesia and

9

Analgesia. https://doi.org/10.1213/ANE.0000000000004203

Purohit, N. (2021). Utilization of delivery and postnatal health services by indigenous women

of a hilly, remote district in India: a struggle for safe motherhood. International Journal

Of Community Medicine And Public Health. https://doi.org/10.18203/2394-

6040.ijcmph20210223

Saluja, B., & Bryant, Z. (2021). How Implicit Bias Contributes to Racial Disparities in

Maternal Morbidity and Mortality in the United States. Journal of Women’s Health.

https://doi.org/10.1089/jwh.2020.8874

Willcox, M. L., Price, J., Scott, S., Nicholson, B. D., Stuart, B., Roberts, N. W., Allott, H.,

Mubangizi, V., Dumont, A., & Harnden, A. (2020). Death audits and reviews for reducing

maternal, perinatal and child mortality. In Cochrane Database of Systematic Reviews.

https://doi.org/10.1002/14651858.CD012982.pub2