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Health care organizations strive to create a culture of safety. Despite technological advances, quality care initiatives, oversight, ongoing education and training, legislation, and regulations, medical errors continue to be made. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. Many errors are attributable to ineffective interprofessional communication.

A comprehensive analysis on an adverse event or near miss that someone experienced during professional nursing career.

Analyze the missed steps or protocol deviations related to an adverse event or near miss.
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 leading to the event.
Explain the extent to which the incident was preventable.
Research the impact of the same type of adverse event or near miss in other facilities.
Analyze the implications of the adverse event or near miss for all stakeholders.
Evaluate the short- and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze each stakeholder’s contribution to the event.
Analyze the interprofessional team’s responsibilities and actions. Explain what measures each interprofessional team member should have taken to create a culture of safety.
Describe any change to process or protocol implemented after the incident.
Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.

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