The goal of this assessment is to allow you to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a QI initiative to prevent future incidents. It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself in as a health care professional.
Health care organizations strive for a culture of safety. Yet, despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation, and regulations, medical errors continue to occur. 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.
Historically, medical errors were reported and analyzed in hindsight. Today, QI initiatives attempt to be proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by new technologies and reporting metrics, adverse events and near misses can provide insight into potential ways to improve care delivery and ensure patient safety.
For clarification, the National Quality Forum (n.d.) defines the following:

Adverse event: An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.
Near miss: An event or a situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention.