NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

Name

Capella University

NURS-FPX 6016 Quality Improvement of Interprofessional Care

Prof. Name

Date

Adverse Event or Near-Miss Analysis

In the complex and dynamic healthcare environment, patient safety remains paramount. Despite significant advancements in medical technology, training, and protocols designed to safeguard well-being, adverse events and near misses continue to occur, posing substantial patient risks and challenging healthcare professionals to seek continuous improvement. This assessment delves into the critical analysis of a specific adverse event or near miss encountered in professional nursing practice, aiming to dissect the multifaceted layers contributing to such incidents.

This report sheds light on the immediate and underlying factors leading to the event through a detailed examination. It proposes a comprehensive Quality Improvement (QI) initiative tailored to address these issues. By integrating evidence-based practices and leveraging insights from existing research, the initiative seeks to enhance patient safety, reduce the incidence of similar events in the future, and foster a culture of proactive risk management within healthcare settings. This assessment underscores the importance of reflective practice, interdisciplinary collaboration, and the relentless pursuit of excellence in patient care, embodying the commitment to turning challenges into opportunities for systemic improvement.

Analysis of Implications of an Adverse Event or a Near Miss for All Stakeholders

As a nurse in a busy hospital ICU, I recently encountered a near-miss event emphasizing the importance of effective communication and adherence to medication safety protocols. One afternoon, while preparing to administer medication to a critically ill patient, I noticed a discrepancy between the dosage ordered by the physician and the dosage listed in the patient’s electronic health record. Upon further investigation, I realized there had been a miscommunication between the physician and the nurse who had transcribed the order, resulting in the incorrect dosage being entered into the system. Immediately recognizing the potential danger posed to the patient, I halted the medication administration process and alerted the physician and my nursing supervisor.

Together, we thoroughly reviewed the situation, confirming the error and ensuring that the patient received the correct medication dosage as prescribed. Although the patient suffered no harm, the incident prompted significant concern among the interprofessional team regarding the underlying factors contributing to the near-miss event. The near-miss event revealed the risks associated with administering incorrect medication dosages, potentially resulting in adverse effects or even death for the patient. It stressed the urgent need for robust communication and strict adherence to medication safety protocols within healthcare settings. The need to prevent adverse outcomes for staff through legal implications such as license cancellation or financial implications such as fines and patients simultaneously. This highlighted the necessity for ongoing nurse training and organizational support to enhance medication safety protocols and ensure staff competency in error and prevention (Shin et al., 2020).

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

In response to the near-miss event, our interprofessional team embarked on a comprehensive analysis to identify the root causes and implications of the incident. Through a series of meetings and collaborative discussions, we identified several critical areas for improvement, including communication protocols, medication reconciliation processes, and staff training initiatives. Leveraging the principles of root cause analysis, we delved into the systemic factors that contributed to the near-miss event, such as time pressures, communication barriers, and workflow inefficiencies (Wolf et al., 2020). Drawing upon evidence-based practices and input from frontline staff, we developed a multifaceted quality improvement plan to prevent future adverse events or near misses. This plan included implementing standardized communication tools, such as read-backs and clarification protocols, to enhance accuracy and reduce the risk of miscommunication. We also instituted regular audits of medication administration processes to identify discrepancies and reinforce adherence to established protocols (Stangle et al., 2021).

Recognizing the importance of ongoing education and training, we organized mandatory workshops and simulations focused on medication safety, communication skills, and error reporting. By empowering staff with the knowledge and resources needed to identify and mitigate risks, we aimed to foster a culture of safety and accountability within our unit (Geoffrion et al., 2020). In the short term, patients and families experience increased anxiety and mistrust in the healthcare system, like hesitancy to follow treatment plans or reluctance to seek further medical care. Similarly, the interprofessional team faces heightened stress and scrutiny, leading to decreased morale and potential turnover (Rushton et al., 2021). In the long term, patients could suffer lingering psychological impacts, such as post-traumatic stress disorder (PTSD), affecting their quality of life and healthcare-seeking behaviors.

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

Additionally, the facility may encounter reputational damage, resulting in decreased patient volume and community support. Community trust may also diminish, impacting the facility’s relationships with local stakeholders and potential donors (Boamah et al., 2022). While the incident served as a sobering reminder of the potential consequences of communication breakdowns and protocol deviations, it also presented an opportunity for growth and improvement. Through this analysis, the interdisciplinary team has gained valuable insights into the importance of effective communication and medication reconciliation procedures. These lessons learned will inform the team’s approach to preventing similar incidents in the future. The interdisciplinary team remains committed to ensuring the highest patient safety and quality care standards through our collective efforts. The interprofessional team continually strives to learn from this experience and implement measures to prevent future adverse events or near misses.

Root Cause Analysis

A breakdown in medication safety protocols and communication occurred during the administration of medication to a critically ill patient, which led to a near-miss event in the intensive care unit. A discrepancy between the physician’s ordered dosage and the one recorded in the patient’s electronic health record (EHR) was identified, revealing a miscommunication between the physician and the nurse responsible for transcribing the order. The missed steps primarily revolved around communication and medication reconciliation. There needed to be more communication between the physician and the nurse during the order transcription process, possibly due to interruptions or unclear verbal orders. Additionally, a failure in medication reconciliation led to an inaccurate dosage entry into the EHR, emphasizing the need for thorough verification procedures (Abraham et al., 2021).

Utilizing standardized communication tools and fostering a culture of open communication could have prevented the event. Read-backs and clarification protocols could ensure accurate transcription while empowering team members to raise concerns and facilitate early detection of discrepancies (Fuchshuber & Greif, 2022). The event was largely preventable with effective communication and adherence to medication safety protocols. Clear communication and robust reconciliation processes could have identified and rectified the discrepancy before medication administration, underscoring the importance of ongoing training and education initiatives (Aldawood et al., 2020). Further information on the nature of the miscommunication, potential contributing factors, and the effectiveness of existing protocols would enhance the analysis. Understanding stakeholders’ perspectives could provide insights into broader implications and improvement opportunities.

Quality Improvement Actions

In response to the near-miss event in the ICU, several quality improvement (QI) actions and technologies can be implemented to enhance patient safety and reduce risks. One key technology is the utilization of electronic prescribing systems equipped with dose range alerts and medication reconciliation features to mitigate errors related to medication dosage discrepancies (Williams et al., 2021). Additionally, barcode scanning technology at the point of care can bolster medication administration accuracy by verifying medications against the patient’s electronic record. Integrating communication platforms into electronic health records (EHRs) can facilitate clear and documented communication among healthcare providers, reducing the risk of miscommunication errors. It’s crucial to ensure the appropriate utilization of these technologies through comprehensive training and continuous monitoring to optimize their effectiveness (Lahti et al., 2022).

 In addition to technology solutions, ongoing education and training programs for healthcare staff are essential to ensure the appropriate utilization of these tools and foster a safety culture. Collaboration with peer institutions through networks or conferences can facilitate knowledge sharing and the adoption of successful strategies (Ting et al., 2021). Furthermore, regular audits and evaluations of QI initiatives are necessary to monitor their effectiveness and identify areas for further improvement. Learning from other institutions’ experiences through benchmarking and collaboration can provide valuable insights into best practices for preventing similar events.

Analyzing relevant metrics from the facility’s dashboard, such as medication error rates and adherence to safety protocols, can inform targeted interventions to address underlying issues contributing to near-miss events (Akmal et al., 2021). Furthermore, reviewing external research and data on medication safety practices can offer additional insights into effective strategies for preventing errors. By leveraging data-driven approaches and insights from external sources, healthcare institutions can implement evidence-based QI initiatives to drive meaningful improvements in patient care delivery and enhance patient safety in critical care settings. This comprehensive approach integrates technological advancements and organizational strategies to create a robust framework for patient safety and quality improvement (Gage et al., 2022).

Quality Improvement Initiative

In response to the near-miss event in our institution’s ICU, a structured quality improvement initiative will be implemented to prevent future adverse events or near misses. The incident will be managed systematically, involving incident reporting, root cause analysis (RCA), and ongoing monitoring. Incident reports will be promptly collected to ensure transparency, and RCA will be conducted to identify underlying factors contributing to the event, such as communication breakdowns or workflow inefficiencies. Regular monitoring of key metrics related to medication safety and communication effectiveness will be undertaken to track progress and identify areas for improvement (Bickley & Torgler, 2021). 

Numerous evidence-based quality improvement initiatives have effectively prevented similar adverse events or near misses. These initiatives include implementing standardized communication tools like read-backs and clarification protocols, utilizing electronic prescribing systems with dose range alerts, and incorporating barcode scanning technology at the point of care (Vejdani et al., 2022). Research studies, such as those conducted by Wolf et al. (2020), have demonstrated the effectiveness of these interventions in reducing medication errors and improving patient safety outcomes. These initiatives have proven successful in mitigating risks by addressing common vulnerabilities in the medication administration process and communication channels.

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

Several elements will be applied within our institution to prevent future adverse events or near misses. Comprehensive education and training programs will be provided to healthcare staff to ensure proficiency in effectively utilizing communication tools and technology solutions. Workflow processes will be reviewed and optimized to minimize interruptions and distractions during medication administration, thus reducing the likelihood of errors (Senbekov et al., 2020). Continuous monitoring of key performance indicators, coupled with feedback mechanisms, will facilitate early detection of potential issues and allow for timely intervention. Promoting transparency and facilitating efforts towards continuous improvement can be achieved by cultivating a safety culture where employees feel empowered to report concerns without fear of reprisal (Rosis. Et al., 2020)

Sensitive and sound outcome measures will be employed to evaluate the effectiveness of these quality improvement initiatives. Outcome measures will include reducing medication errors and near misses, improving adherence to medication safety protocols, enhancing communication effectiveness among healthcare providers, and patient satisfaction regarding medication administration processes. By systematically evaluating these outcome measures, we can objectively assess the impact of the quality improvement initiatives on reducing risks and increasing patient safety within our institution’s ICU (Shitu et al., 2020).

Conclusion

In conclusion, the analysis of the near-miss event in the ICU underscores the critical importance of effective communication and adherence to medication safety protocols in ensuring patient well-being. By conducting a root cause analysis and implementing a comprehensive quality improvement initiative, our interprofessional team aims to prevent future adverse events or near misses. By integrating evidence-based practices, technology solutions, ongoing education, and continuous monitoring, we are committed to fostering a safety culture and driving meaningful improvements in patient care delivery within our institution’s ICU. This proactive approach reflects our unwavering dedication to turning challenges into opportunities for systemic enhancement and upholding the highest standards of patient safety.

References

Abraham, J., Galanter, W. L., Touchette, D., Xia, Y., Holzer, K. J., Leung, V., & Kannampallil, T. (2021). Risk factors associated with medication ordering errors. Journal of the American Medical Informatics Association, 28(1), 86–94. https://doi.org/10.1093/jamia/ocaa264 

Akmal, A., Podgorodnichenko, N., Foote, J., Greatbanks, R., Stokes, T., & Gauld, R. (2021). Why is quality improvement so challenging? A viable systems model perspective to understand the frustrations of healthcare quality improvement managers. Health Policy, 125(5), 658–664. https://doi.org/10.1016/j.healthpol.2021.03.015 

Aldawood, F., Kazzaz, Y., AlShehri, A., Alali, H., & Al-Surimi, K. (2020). Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool. BMJ Open Quality, 9(1), e000753. https://doi.org/10.1136/bmjoq-2019-000753 

Bickley, S. J., & Torgler, B. (2021). A systematic approach to public health – novel application of the human factors analysis and classification system to public health and COVID-19. Safety Science, 105312. https://doi.org/10.1016/j.ssci.2021.105312 

Boamah, S. A., Weldrick, R., Havaei, F., Irshad, A., & Hutchinson, A. (2022). Experiences of healthcare workers in long-term care during covid-19: A scoping review. Journal of Applied Gerontology, 073346482211462. https://doi.org/10.1177/07334648221146252 

Fuchshuber, P., & Greif, W. (2022). Creating effective communication and teamwork for patient safety. The SAGES Manual of Quality, Outcomes and Patient Safety, 443–460. https://doi.org/10.1007/978-3-030-94610-4_23 

Gage, A. D., Gotsadze, T., Seid, E., Mutasa, R., & Friedman, J. (2022). The influence of continuous quality improvement on healthcare quality: A mixed-methods study from Zimbabwe. Social Science & Medicine, 298, 114831. https://doi.org/10.1016/j.socscimed.2022.114831 

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

Geoffrion, S., Hills, D. J., Ross, H. M., Pich, J., Hill, A. T., Dalsbø, T. K., Riahi, S., Martínez-Jarreta, B., & Guay, S. (2020). Education and training for preventing and minimizing workplace aggression directed toward healthcare workers. Cochrane Database of Systematic Reviews, 9. https://doi.org/10.1002/14651858.cd011860.pub2 

Lahti, C. L., Kivivuori, S.-M., Lehtonen, L., & Schepel, L. (2022). Implementing a new electronic health record system in a university hospital: The effect on reported medication errors. Healthcare, 10(6), 1020. https://doi.org/10.3390/healthcare10061020 

Rosis, S. D., Cerasuolo, D., & Nuti, S. (2020). Using patient-reported measures to drive change in healthcare: The experience of the digital, continuous and systematic PREMs observatory in Italy. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-05099-4 

Rushton, C. H., Thomas, T. A., Antonsdottir, I. M., Nelson, K. E., Boyce, D., Vioral, A., Swavely, D., Ley, C. D., & Hanson, G. C. (2021). Moral injury and moral resilience in health care workers during COVID-19 pandemic. Journal of Palliative Medicine, 25(5). https://doi.org/10.1089/jpm.2021.0076 

Senbekov, M., Saliev, T., Bukeyeva, Z., Almabayeva, A., Zhanaliyeva, M., Aitenova, N., Toishibekov, Y., & Fakhradiyev, I. (2020). The recent progress and applications of digital technologies in healthcare: A review. International Journal of Telemedicine and Applications. https://www.hindawi.com/journals/ijta/2020/8830200/ 

Shitu, Z., Aung, M. M. T., Tuan Kamauzaman, T. H., & Ab Rahman, A. F. (2020). Prevalence and characteristics of medication errors at an emergency department of a teaching hospital in Malaysia. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-4921-4 

Shin, S., Park, J. D., & Shin, J. H. (2020). Improvement plan of nurse staffing standards in Korea. Asian Nursing Research, 14(2), 57–65. https://doi.org/10.1016/j.anr.2020.03.004 

Stangle, A. (2021). Safe and effective patient handoffs. Honors Capstones. https://huskiecommons.lib.niu.edu/studentengagement-honorscapstones/979/ 

Ting, J., Garnett, A., & Donelle, L. (2021). Nursing education and training on electronic health record systems: An integrative review. Nurse Education in Practice, 55, 103168. https://doi.org/10.1016/j.nepr.2021.103168 

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

Vejdani, M., Varmaghani, M., Meraji, M., Jamali, J., Hooshmand, E., & Vafaee-Najar, A. (2022). Electronic prescription system requirements: A scoping review. BMC Medical Informatics and Decision Making, 22(1). https://doi.org/10.1186/s12911-022-01948-w 

Williams, J., Malden, S., Heeney, C., Bouamrane, M., Holder, M., Perera, U., Bates, D. W., & Sheikh, A. (2021). Optimizing hospital electronic prescribing systems. Journal of Patient Safety, Publish Ahead of Print(2). https://doi.org/10.1097/pts.0000000000000867 

Wolf, L., Parker, S. H., & Gleason, J. L. (2020). Human factors in healthcare. Patient Safety and Quality Improvement in Healthcare, 319–333. https://doi.org/10.1007/978-3-030-55829-1_20