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Describe how the event resulted from a patient’s medical management rather than from the underlying condition.
Identify and evaluate the missed steps or protocol deviations that led to the event.
Discuss the extent to which the incident was preventable.
Research the impact of the same type of adverse event or near miss in other facilities.
Evaluate both short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze how it was managed and who was involved.
Analyze the responsibilities and actions of the interprofessional team. Explain what measures should have been taken and identify the responsible parties or roles.
Describe any change to process or protocol implemented after the incident.
Analyze the quality improvement technologies that were put in place to increase patient safety and prevent a repeat of similar events.
Determine whether the technologies are being utilized appropriately.
Explore how other institutions integrated solutions to prevent these types of events.
Identify the salient data that is associated with the adverse event or near miss that is generated from the facility’s dashboard. (By dashboard, we mean the data that is generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management.)
Analyze what the relevant metrics show.
Explain research or data related to the adverse event or near miss that is available outside of your institution. Compare internal data to external data.
Explain how the process or protocol is now managed and monitored in your facility.
Evaluate how other institutions addressed similar incidents or events.
Analyze QI initiatives developed to prevent similar incidents, and explain why they are successful. Provide evidence of their success.
Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.
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