NURS FPX 6016 Assessment 1
[Student Name]
Capella University
Professor’s Name
September 2025
NURS FPX 6016 Assessment 1: Adverse Event or Near Miss Analysis
In the medical industry, at least 10% of patients experience adverse events every day. “Destructive” or “having a negative impact on a patient’s health or recovery is the best method to describe adverse events (Skelly, 2022). Unpleasant events include unexpected deaths, pharmaceutical errors, falls, and hospital-acquired infections. Adverse events can be classified as either preventable or unavoidable. In order to identify common characteristics that continue to cause adverse events and strategies to prevent them in the future, NURS FPX 6016 Assessment 1 will examine every incident that has occurred in the previous six months.
A 63-year-old man’s son took him to the emergency room while stating that his father had changed and that he was no longer aroused at times. After receiving care, the patient was hostile, resisted getting well, and repeatedly tried to get out of the emergency room. He was a danger to himself and others, so the staff had to hold him. As soon as the doctor could visit the patient, he started a 5150, an involuntary 72-hour (about three-day) hold on the patient. The psychiatric staff at the hospital assessed the patient after admission and determined that the 5150 should be canceled within 48 hours.
In a near-miss adverse event, the patient removed all hospital clothing and IVs and left the hospital without anyone knowing the night after the initial assessment and the nurse on the med-surg floor gave night medication. Rather than leaving by the main entrance, where security is stationed, they had forced their way out through one of the side entrances. Hospital staff changed the intercom system after learning that the patient was no longer in his room. In the meantime, a patient who had been hit by a car while walking down the street had just been taken 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 serves as evidence of a negative outcome that may have been
prevented had the right precautions been taken. 5150 places a patient on hold for 72 hours and assigns a 1:1 sitter to monitor the patient closely
Analysis of Missed Steps Related to the Adverse Event
Every patient on a 5150 in the hospital must have a personal caregiver at all times, and they must remove anything they think could be used against them or others. It is possible to inform the medical staff that patients with altered mentalities on the 5150 are also susceptible to eloping and will likely attempt to evade medical treatment if possible. According to NURS FPX 6016 Assessment 1, staff members should regularly supervise patients who are recognized as elopement risks (Phillips et al., 2018).
The nurse who was in charge of the patient’s care should have reexamined the stated risk factor and assessed if the individual in need still needed a personalized caregiver in light of the previously detailed circumstances. This is because the 5150 hold was removed prior to the 72-hour mark. Regretfully, the great majority of floor caregivers are unaware of the factors that increase the likelihood of elopement and how to stop it. According to the Joint Commission’s monitor event statistics, the most common reasons for the elopement risks that need to be addressed were improper measures, interventions, and team connection, and the preventive actions implemented (Marlett et al., 2023).
NURS FPX 6016 Assessment 1: Implication of the Adverse Event on Stakeholders
Healthcare stakeholders are involved in funding, rules and procedures, keeping an eye on the caliber of services rendered, and guaranteeing patient satisfaction. In the case of a hospital adverse event, the patient and their family, the healthcare provider who is administering the therapy, and the stakeholders are all affected. Responsible stakeholders who oversee patient care, including staff members who deal with patients, have an obligation to ensure the safe handling of patients (Cho et al., 2020). In the event of a failure, the stakeholders first investigate the incident to
determine the impact on the patient, family, and organization. They look at the records and charts to determine what led to the occurrence and how to make changes to keep it from happening again. When the JACHO examines the institution, they want to know what happened, whether they think the entire organization needs to be investigated to find any care delivery flaws, and if it is safe to keep the place open to the public. Such unfavorable incidents in organizations generate concerns. NURS FPX 6016 Assessment 1 highlights the need for an elopement risk protocol among patients. This experience forced the stakeholders to develop a plan of action and procedure regarding the risk of elopement and how it can be assessed, implemented, and evaluated.
Evaluation of Quality Improvement Technologies
The stakeholders first looked at security in relation to restricting patient or visitor video recordings after carefully reviewing the data. To improve patient care, it was determined that more security cameras were required at the staff exits. Temecula Valley Hospital used to have video surveillance, which was very beneficial to warn the staff whenever a patient was not complying. The one-to-one sitter strategy is highly helpful but also very costly because an employee would sit and watch over the entire shift. Unfortunately, they removed them at random; there were fewer falls and elopements when they were in use. One staff member kept an eye on four or five patients at once while they were in a secure room. If the patient did not comply with the monitor’s instructions, he would activate an alarm to notify the staff that the patient was not acting appropriately. The effects of telemonitoring have been studied, and the results indicate that remote monitoring reduces the incidence of elopement instances and falls (Hattersley-Gray, 2018).
Relevant Metrics of Quality Improvement Plan
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 incidents, close calls, or potentially
dangerous situations. When there are measurable negative events occurring at the facility, the facility takes the appropriate precautions to avoid them. However, not all adverse events can be measured.
Outline for a Quality Improvement Initiative
Temecula Valley Hospital will once again make its telemonitoring equipment available to patients who need personal monitoring. Additionally, a new tool of elopement will be adopted by the hospital, and staff members will be properly trained in its use. Every patient sent to the emergency room will use this tool prior to being transferred to the medical care floor. The team of professionals will create a treatment plan to monitor the progress if NURS FPX 6016 Assessment 1 indicates that the patient needs therapies to avoid elopement. The patient’s family, security, nurses, and doctors will collaborate on this. Stakeholders and medical providers must fully support the implementation of a quality improvement strategy.
Conclusion
According to NURS FPX 6016 Assessment 1, administrative events are inevitable in the medical industry because of the continuously evolving research and data collected to support evidence-based best practices. Institutions far too often experience unwanted events, both preventable and unavoidable. Together, the organization and stakeholders should examine the documentation and charting to identify the areas where attention was subpar in order to guarantee that remedial actions are taken and that the mistake does not occur again. The required steps can be taken to improve patient safety and care with open and effective communication, a supportive multidisciplinary team that collaborates tirelessly, and staff education.
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/
