NURS FPX 6016 Assessment 1
[Student Name]
Capella University
Professor’s Name
August 2025
NURS FPX 6016 Assessment 1: Adverse Event or Near Miss Analysis
In the medical field, adverse events occur on a daily basis, affecting at least 10% of patients. The best way to characterize adverse occurrences is as destructive or having a negative impact on a patient’s health or recovery (Skelly, 2022). Unexpected fatalities, prescription mistakes, falls, and hospital-acquired infections are a few examples of unpleasant occurrences. Adverse events may be divided into two categories: avoidable and unpreventable. NURS FPX 6016 Assessment 1 will look at every incident that has happened in the past six months and find some common characteristics that continue to cause adverse events as well as ways to prevent them in the future.
The son of a 63-year-old man brought him to the emergency room, complaining that his father had changed and that there were times when he was no longer even aroused. Following treatment, the patient became aggressive, refused to receive treatment, and made many attempts to escape the emergency department. Staff had to detain him because he posed a risk to both himself and other people. The physician initiated a 5150, an involuntary 72-hour (about three-day) hold on the patient, as soon as he was able to visit the patient. Following the patient’s admission, the hospital’s psychiatric professionals evaluated him or her and decided that the 5150 should be revoked within 48 hours. The same night following the initial assessment and the administration of night medication by the nurse in med surgical floor, the patient took off all the hospital clothes and IVs and left the hospital without anybody noticing, which was a near miss adverse event. They had pushed past the security by exiting one of the side entrances instead of exiting the main entrance where the security is. Upon discovering that the patient was no more in his room, the hospital’s personnel switched the intercom system. Meanwhile, the emergency room had just brought in a patient who had been struck by a car while strolling down the street. When the nurse on the floor went to investigate, it was discovered that the patient who had been struck was the one who had eloped. The patient had died a short time after coming back because of serious head injury. This
incident bears witness to an adverse event that would have been avoided with the proper measures that were appropriately implemented. 5150 puts a patient under a seventy-two-hour time frame of hold as well as a 1:1 sitter to tightly guard the patient.
Analysis of Missed Steps Related to the Adverse Event
Every patient who is placed on a 5150 in the hospital needs to have a personal caregiver at all times, and anything they believe may be used as a instrument against them or others needs to be taken out of the area. The medical personnel can be advised that patients with changed mentality on the 5150 are also at risk of eloping, and that they are likely to try to avoid receiving medical care if given the opportunity. Additionally, a patient who is identified as an elopement risk must be closely monitored, and staff members should be trained to recognize at-risk patients as emphasized in NURS FPX 6016 Assessment 1(Phillips et al., 2018).
The registered nurse who took on the duty of caring for the patient should have reexamined the alleged risk cause and discovered whether the patient in question still needed a one-on-one sitter in light of the previously described circumstance, since the 5150 hold was lifted before the 72-hour mark. Unfortunately, the vast majority of floor caregivers are unconscious of the risk cause for elopement and how to prevent it from happening. The lookout event statistics of the Joint Commission revealed that lack of proper measure, interventions and connection between the team and the preventive measures taken were the most prevalent causes of the elopement risks that should be addressed (Marlett et al., 2023). The aspects that led to this unfortunate event are the absence of human action, hospital policy and work and lack of education on elopement risk factors and assessment need to the staff.
NURS FPX 6016 Assessment 1: Implication of the Adverse Event on Stakeholders
Stakeholders in healthcare play a part in funding, regulations and processes, monitoring the quality of services provided, and ensuring patient happiness. In the event of a hospital adverse
event, the individual receiving treatment and their relatives, the healthcare provider involved in the patient’s care, and the stakeholders are all impacted. Ensuring the safe handling of patients is the duty of responsible stakeholders who are in charge of their care; this option also includes the staff members who interact with the patients (Cho et al., 2020). When failures happen, the stakeholders initially examine the incidence with the aim of establishing the effect that the patient, family, and organization experience. To find what caused the incident to happen and how to change it to prevent it from happening again, they consult the documentation and charts. The JACHO visits the facility to inquire about the incident, whether they believe it is necessary to investigate the entire organization to find any care delivery lapses, and whether the location is safe to remain open to the public. When such negative events occur in organizations, it raises questions. This experience challenged the stakeholders to design a plan of action and procedure in relation to the risk of elopement and the manner in which it can be assessed, implemented and evaluated as being necessary to have an elopement risk protocol in place among patients as highlighted in NURS FPX 6016 Assessment 1.
Evaluation of Quality Improvement Technologies
Following a thorough examination of the data, the stakeholders originally examined security as regards limiting patient or visitor video recordings. The necessity of more security cameras on the staff exits points was introduced to facilitate the patient condition. One-to-one sitter approach is quite useful but is also extremely expensive as an employee would sit and watch over the whole shift, Temecula Valley hospital used to have video surveillance, which was very helpful to alert the staff whenever a patient was failing to comply. Sadly enough, they took them away on a whim, when they were in service, the number of falls and elopements was smaller. It was four to five patients monitored at a time by one employee who watched inside a secure room. In case the patient failed to follow directives of the monitor person, he would raise an alarm to alert the staff
that the patient was not behaving accordingly. Research has been conducted on the impact of tele-monitoring and they regard remote monitoring as a decrease in the number of falls and cases of elopement (Hattersley- Gray, 2018).
Relevant Metrics of Quality Improvement Plan
Safety and our efforts to keep patients safe are topics that individuals and groups in the healthcare industry frequently address. AHRQ employs dashboards, which are typically used in event-specific reporting that is common to the common trend format. Such reports may be regarding incidences, near misses and possibly unsafe conditions. In the case of adverse events taking place in the facility when they are quantifiable the facility makes the necessary steps in order to take preventive actions, however not all adverse events can be quantified and preventive actions cannot be taken.
Outline for a Quality Improvement Initiative
Patients who require one-on-one monitoring will be able to use Temecula Valley Hospital’s telemonitoring technology again. Additionally, a new elopement assessment instrument will be used by the hospital, and staff members will get sufficient training on its usage and application. This tool will be used by each patient who is transferred to the emergency room and before they get transferred to the medical care floor. The interdisciplinary team will develop a care plan to monitor the patient’s condition and address the cause for admission if it is found that the patient needs therapies to prevent elopement as highlighted in NURS FPX 6016 Assessment 1. This will be a collaborative effort between the patient’s family, security, doctors, and nurses. An company requires the full support of its stakeholders and medical providers in order to implement a quality improvement plan.
Conclusion
In NURS FPX 6016 Assessment 1, it is noted that in the medical field, administrative events are unavoidable due to the constantly changing research and data gathered to support evidence-based best practices. Unwanted events, both avoidable and unavoidable, occur much too frequently in institutions. To ensure that corrective measures are taken and that the error does not happen again, the organization and stakeholders should work together to review the documentation and charting to find the areas where the care was inadequate. With open, transparent, and efficient communication, a supportive multidisciplinary team that works relentlessly together, and staff education, the necessary actions may take place and improve the safety and treatment of patients.
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/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/
