NURS FPX 6016 Assessment 1
[Student Name]
Capella University
[Prof. Name]
September 2025
NURS FPX 6016 Assessment 1: Adverse Event or Near Miss Analysis
At least 10% of patients in the medical industry have adverse occurrences every day. Adverse event definition is as something that damages or negatively impacts the recovery or health of a patient (Skelly, 2022). Hospital-acquired infections, falls, unexpected deaths and prescription mistakes are unpleasant events. There are two types of adverse events: preventable and unavoidable. Every incident that has occurred in the last six months will be examined in NURS FPX 6016 Assessment 1 in order to identify common traits that continue to result in unfavorable outcomes as well as strategies to avoid them in the future along with understanding about what is an adverse event.
One 63-year-old man’s son took him to the ER, stating that his father had changed and that sometimes he wasn’t even aroused anymore. After receiving treatment, the patient become hostile, resisted getting help, and repeatedly tried to get out of the emergency room. Because he was a danger to himself and others, staff had to place him under arrest. As early as he could see the patient, the doctor made a 5150, an involuntary 72-hour (approximately three-day) hold on the patient. After admission, the mental health professionals of the hospital examined the patient and decided that the 5150 should be canceled in 48 hours. The patient went home at night, the night after the nurse on the med surgical floor had done the preliminary examination and given night medicine and had no one who saw her, removing all hospital clothes and IVs. This was a near miss adverse event. Instead of leaving by the main entrance, where security is stationed, they had forced their way out through one of the side entrances. When hospital staff realized the patient was no longer in his room, they changed the
intercom system. A patient who had been hit by a car while walking down the street had just been brought into the emergency room. The patient who had been struck was found to be the one who had eloped when the floor nurse went to look into it. Due to a severe head injury, the patient passed away shortly after returning. This episode depict that this is a near miss an adverse event that may have been prevented had the right precautions been taken.5150 keeps a patient on hold (72 hours) and gives a 1:1 sitter to closely supervise the patient.
Examination of the Adverse Event-Related Missed Steps
At all times, a personal caregiver must be present for each patient on a 5150 in the hospital, and they must remove anything they think could be used against them or others. Medical staff should be informed that patients with altered mentalities on the 5150 are also susceptible to eloping and will likely attempt to evade medical treatment if given the chance. As stressed in NURS FPX 6016 Assessment 1, staff members should be taught to identify at-risk patients, and patients who are recognized as elopement risks need to be regularly observed (Phillips et al., 2018).
The registered nurse who assumed the care of the patient ought to have reevaluated the purported risk factor and determined whether or not the patient still required a one-on-one sitter given the circumstances that were reported to have occurred earlier. This is as a result of the 5150 hold being lifted before the 72-hour deadline. Unfortunately, the vast majority of floor caregivers do not know how to prevent elopement or what variables make it more likely. The Joint Commission’s watch event statistics show that ineffective measures, interventions, team connection, and preventative actions were the most often cited causes of elopement risks that require
attention (Marlett et al., 2023). This sad occurrence was attributed to several factors among them human inactivity, hospital policies and practices, and ignorance of the staff about risks of elopement and need to assess them.
NURS FPX 6016 Assessment 1: The Impact of the Adverse Event on the Stakeholders
Healthcare stakeholders can be involved in funding, regulations and policies, monitoring the quality of services offered, and their satisfaction with their patients. A hospital adverse event affects the patient and his or her relatives, the health practitioner providing the treatment, and the involved parties (stakeholders). The employees who engage with the patients and other responsible parties that oversee patient care have a responsibility to ensure that they handle the patients safely (Cho et al., 2020). In case of a failure, the first step that the stakeholders will take is to investigate what has happened and how it impacted the patient, family, and organization. They look through the records and charts to determine adverse event definition and what led to the occurrence and how to make changes to keep it from happening again. The JACHO’s visit to the facility includes questions about the incident, whether a thorough examination of the entire organization is necessary to identify any deficiencies in care delivery, and whether the location is secure enough to be accessible to the public. Concerns are raised by such negative events in organizations. This experience compelled the stakeholders to create a plan of action and procedure regarding the risk of elopement and how it can be assessed, implemented, and evaluated. NURS FPX 6016 Assessment 1 highlights the importance of an elopement risk measure amongst patients.
Assessment of Technologies for Quality Improvement
Upon a thorough review of the data, the first think of the stakeholders was on security in terms of curbing camera shot of patients or visitors. It was concluded that additional security cameras at the staff exits were necessary to enhance patient care. In the past, Temecula Valley Hospital had video surveillance, which was very helpful in alerting the personnel when a patient was not following instructions. Because an employee would sit and keep watch over the entire shift, the one-to-one sitter technique is incredibly beneficial but also very expensive. Sadly, they took them out at random; when they were in use, fewer people fell and eloped. Four or five patients at a time were monitored by a single staff member in a secure room. The monitor would sound an alarm to alert the personnel to the patient’s inappropriate behavior if the patient disregarded his instructions. Research on telemonitoring’s impacts has revealed that it lowers the amount of elopement and fall incidents (Hattersley-Gray, 2018).
Relevant Quality Improvement Plan Metrics
People and organizations in the healthcare sector regularly discuss safety and our efforts to keep patients safe. AHRQ uses dashboards, which are commonly utilized in the conventional trend style for event-specific reporting. These reports could be about near misses an adverse event, close calls, or potentially dangerous situations. When there are quantifiable adverse events occurring at the facility, the facility takes the appropriate precautions to avoid them; however, not all adverse events can be quantified, and hence preventative measures cannot be implemented without knowing that what are adverse events.
A Quality Improvement Initiative Outline
Patients who require one-on-one monitoring will once again have access to Temecula Valley Hospital’s telemonitoring technology. Also, the hospital will introduce a new elopement assessment tool and will offer personnel adequate training on how to use it. This tool will be applied to every patient that is referred to the emergency room before they are transferred to the medical care floor. The interdisciplinary team will create a treatment plan to monitor the patient in terms of progress and the cause of admission in case it is discovered that the patient requires therapies to prevent the elopement as outlined in NURS FPX 6016 Assessment 1. The patient’s family, security, nurses, and doctors will collaborate on this. Stakeholders and healthcare providers must fully support the implementation of a quality improvement strategy.
Conclusion
NURS FPX 6016 Assessment 1 states that administrative events are inevitable to the medical field because of the ever evolving research and data collected to support the evidence-based best practices. The events that are unwanted are avoidable and unavoidable and occur far too frequently in institutions. To make sure that corrective actions are implemented and that the error does not happen in the future, the organization and stakeholders are to collaborate in order to examine the documentation and charting and identify the spheres in which the care was inefficient. An effective multidisciplinary team, diligent work, staff education, open, honest and effective interaction can contribute to better patient safety and care
References
Cho, I., Lee, M., & Kim, Y. (2020, August). What are the main patient safety concerns of healthcare stakeholders: A mixed-method study of web-based text. International journal of medical informatics. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7198194/
Hattersley-Gray, R. (2018, April 9). Responding to elderly patient elopement and wandering: Part 2. Campus Safety Magazine. https://www.campussafetymagazine.com/news/elderly- patient-elopement-wandering/
Marlett, J. E., Vacovsky, B. A., Krug, E. A., Ha-Johnson, T. M., & Hill, S. A. F. (2023). Elopement: Evidence-based mitigation and management. Worldviews on evidence-based nursing, 20(6), 634–641. https://doi.org/10.1111/wvn.12683
Phillips, L. A., Briggs, A. M., Fisher, W. W., & Greer, B. D. (2018). Assessing and treating elopement in a school setting. TEACHING Exceptional Children, 50(6), 333-342. https://doi.org/10.1177/0040059918770663
Skelly, C. L. (2022, February 9). Adverse events. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK558963/
