Adverse Event or Near-Miss Analysis

Write a comprehensive analysis (5-7 pages) of an adverse event or near miss from your nursing experience. integrate research and data on the event to propose a quality improvement (QI) initiatiive to your current organization. Instructions attached.
Rubric attached and must be minimum proficient or distinguished to pass.

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Adverse Event Analysis

Errors and unsafe care lead to preventable adverse incidents in healthcare organizations. According to Schwendimann et al. (2018), the rate of preventable errors has increased dramatically in healthcare settings, compromising the safety and quality of patient care and health outcomes. Additionally, adverse events are among the significant causes of disability and death in medical facilities (World Health Organization, 2019). About 10% of the total number of patients in high-income countries are affected by adverse events. Similarly, the rate of adverse events in low- and middle-income countries (LMICs) is relatively high. According to World Health Organization (2019), approximately 134 million adverse events are reported in LMICs annually, resulting in about 2.6 million deaths. This paper presents an adverse event reported in the critical care unit, including missed steps related to the event, the implication of the event to all the stakeholders, metrics justifying the need for improvement, and a proposed quality improvement initiative.

Description of the Adverse Event: Patient Fall

The adverse incident is patient falls reported in the geriatric care unit. Mrs. T is an 82 years old African American female who her elder daughter accompanied during her first visit to the clinic. Her daughter was concerned with her deteriorating health in the past three months. During the interview, her daughter reported that the client was diagnosed with type 2 Diabetes Mellitus (T2DM) for ten years, which she has been managing using insulin injections. Despite using insulin, the client had fallen severely at home in the past month. Additionally, the client had lost memory and was confused about place and time, necessitating medical attention. Physical assessment and the subjective data indicated that the client had dementia. Increased fall incidents were associated with unstable diabetes. According to Yang et al. (2016), lack of glycemic control increases the likelihood of falls among diabetes patients. The healthcare provider recommended Mrs. T be admitted to the geriatric unit for further treatment and close monitoring. The client became disorientated during her hospital stay while moving out of bed to visit the washroom and fell. Mrs. T sustained a fracture in her right leg. Consequently, a surgical procedure was scheduled, increasing her length of stay and treatment cost. Furthermore, the client and her family were dissatisfied with the healthcare organization’s quality and safety of care. In response to this issue, the nurse practitioner on duty denied the high risk of falling, claiming that her blood glucose level was closely monitored during the hospital stay.

Analysis of Protocol Deviation related to the Patient Fall

            Patient fall resulted from a gap in care delivery. Safety measures are implemented in the geriatric unit to prevent falls since the risk of falls is relatively high among elderly patients (Gale et al., 2018). However, the management had failed to ensure that safety measures were observed in this unit, resulting in the adverse event. The management had failed to introduce hourly rounding in this unit. As nurses move around the wards during the hourly rounding, they support patients while moving out of bed, preventing falls. Additionally, the management had failed to ensure that patients’ beds were kept as low as possible to prevent the patients from falling while moving out of bed.

Analysis of the Implications of the Patient Fall for all Stakeholders

This incident had short- and long-term effects on various key stakeholders, including the patient and her family, the management, interprofessional teams, the community, and the facility. First, the patient and her family were affected by the incident. The patient sustained a fracture after the fall, necessitating a surgical procedure, which increased her length of stay and cost of care. In the long run, the fall could result in disability or death. Secondly, the fall incident implied the management. The incident presents the management as irresponsible and less concerned with patients’ safety and well-being. The fall occurred due to the failure of the management to introduce fall prevention measures in the geriatric unit. This incident could be prevented by safety measures such as ensuring that patient beds were as low as possible. Additionally, the management could prevent this issue by recruiting more nurse practitioners to conduct hourly rounding. Nurses would support patients while moving out of bed, preventing falls. Finally, this issue implied interprofessional teams, including doctors, nurses, nutritionists, and physiotherapists. It portrays them as incompetent and less experienced. These team members could have collaborated to provide quality, safe, and holistic care during care delivery. According to Rosen et al. (2018), collaboration results in high-standard and safe patient care during care delivery. Hence, collaboration among interprofessional team members could have reduced the risk of falls in this patient, improving the quality and safety of patient care. Following this incident, the management introduced hourly rounding. This new practice would enable nurses to monitor patients closely and support them while moving out of bed to reduce the risk of falls.

Quality Improvement Technologies related to Patient Falls

The management should adopt quality improvement technologies to prevent patient falls from recurring in the future. This technology involves wearable sensors, which are useful and effective in monitoring and analyzing patients’ stability. Healthcare providers widely use gyroscopes and accelerometers to detect patients’ stability and balance issues. These sensors are fixed on the trunk to assess dynamic and static stability (Rucco et al., 2018). A patient with stability and balance difficulties is then monitored closely to reduce fall risk. Another technology effective in preventing patient falls is the smartphone application. Healthcare practitioners use built-in movement detection functions and accelerometers to detect falls while away from the patient. An alarm is then started to lower the fall effect on the patient. Additionally, medical professionals instantly receive data, alarms, and fall incidents from these applications (Tacconi et al., 2021). Healthcare providers then take action immediately to reduce the effect of falls on patients.

Metrics of the Patient Fall indicating the Need for Improvement

Metrics reflect the performance of a healthcare organization and the quality of care offered to the patients. Metrics associated with patient falls include average hospital stay, cost of care, patient satisfaction. Patient fall is associated with a more extended hospital stay since the client had to undergo surgery to correct the fracture sustained on her right leg during the fall. The longer length of state then increases the cost of care. Another metric portrayed by the fall incident s patient satisfaction. The patient and her family are dissatisfied with the quality and safety of care offered during the hospital stay. They consider it falls as negligence from the healthcare providers and the management. They believe that falls could be prevented through some safety. For instance, nurse practitioners could have monitored the patient closely since she has a fall history, which was reported during the physical assessment.

These metrics reflect low-quality and unsafe patient care. Therefore, the healthcare organization should improve its clinical practices by introducing various safety measures to prevent falls from recurring in the future. Adopting safety measures such as wearable sensors will improve the quality and safety of patient care, preventing falls in the future.

Proposed Quality Improvement Initiative for Preventing Recurrence of Patient Fall

The healthcare organization can prevent patient falls in the geriatric unit by introducing quality improvement initiatives. Specifically, the healthcare organization should introduce the use of wearable sensors. This technology will enable healthcare providers to monitor patients’ stability and balance issues, detecting those at a high risk of falls. According to Khalifa (2019), wearable sensors are highly reliable in monitoring and analyzing patients’ stability. These patients are then monitored closely and accorded the needed support, such as moving out of bed to prevent them from falling. Therefore, incorporating wearable sensors in clinical practices will enhance patient safety, lowering patient fall incidents in the geriatric unit.

Overall, patient falls are adverse events reported in the geriatric unit. This incident is associated with adverse health outcomes, including more extended hospital stay, increased cost of care, and patient dissatisfaction. Patient fall is attributed to healthcare providers’ negligence and a gap in the quality of care. Consequently, the healthcare organization should strive to improve the quality and safety of patient care to prevent patient falls from recurring in the future. The healthcare organization can particularly adopt wearable sensors to monitor patients’ stability and balance issues, detecting those at a high risk of falling. These patients are then monitored closely to prevent them from falling.


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Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist73(4), 433.

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Schwendimann, R., Blatter, C., Dhaini, S., Simon, M., & Ausserhofer, D. (2018). A scoping review is the occurrence, types, consequences, and preventability of in-hospital adverse events. BMC health services research18(1), 521.

Tacconi, C., Mellone, S & and Chiari, L. (2021). Smartphone-based applications for investigating falls and mobility, in 2021 5th International Conference on Pervasive Computing Technologies for Healthcare (PervasiveHealth) and Workshops. IEEE. pp. 258-261

World Health Organization. (2019). Patient Safety.

Yang, Y., Hu, X., Zhang, Q., & Zou, R. (2016). Diabetes mellitus and risk of falls in older adults: a systematic review and meta-analysis. Age and aging45(6), 761-767.