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

Adverse events and near-miss situations are common in healthcare settings. While adverse events are unintended harms caused by medical management, near misses are incidents that could have led to harm but were prevented. Both highlight system vulnerabilities and underscore the importance of robust safety protocols to enhance patient care. This assessment analyzes a similar event in a tertiary care setting. 

In a bustling hospital in New York, nurse Jane was responsible for administering medications to Mr. Smith during her shift in the surgical ward. Due to a busy schedule and multiple interruptions from other patients, Jane inadvertently administered the wrong dosage of insulin to Mr. Smith, who had diabetes. Instead of 10 units, she gave him 20 units. Mr. Smith immediately began to feel dizzy and disoriented, and his blood sugar levels plummeted dangerously low. The attending physician, Dr. Roberts, was alerted and quickly intervened, administering glucose to stabilize Mr. Smith’s condition. Fortunately, Mr. Smith recovered without long-term harm, but the incident caused significant distress to both the patient and the healthcare team. This event prompted a thorough review and led to the implementation of additional safety measures to prevent future medication errors.

Implications of Adverse Event on Stakeholders

The adverse event of a medication error has significant implications for all stakeholders. In the short term, the patient experienced hypoglycemia, causing distress and requiring immediate intervention. The patient’s distressful condition affected his family by anxiety and lack of trust in hospital care. According to the literature, adverse events can significantly erode patient trust, highlighting potential drawbacks to the healthcare system’s medical safety and care quality (Chirinos et al., 2023). This lack of confidence may lead to long-term implications such as fear or reluctance to seek future medical care and possible health repercussions if similar errors occur again.

For the interprofessional team (nurses, physicians, and administrators), the immediate effect is increased stress and analysis, while long-term effects might include mandatory retraining and policy changes. The facility faces potential reputational damage, increased scrutiny from regulatory bodies, and financial costs related to legal liability and implementing corrective measures (Dahlawi et al., 2021). Due to medical negligence, the broader community may lose trust in the hospital, leading to decreased patient volume and community support. This incident underscores the need for a culture of safety and vigilance.

Stakeholders may adopt more stringent checking procedures and improve reporting systems to prevent recurrence, emphasizing a culture of transparency and continuous improvement (Mutair et al., 2021). The analysis assumes that the medication error indicates broader systemic issues within the hospital, requiring robust safety measures and staff training. It presumes the hospital has sufficient resources and commitment to implement corrective measures. Finally, it is assumed that all stakeholders, including the patient, family, and interprofessional team, are motivated to improve patient safety and that the hospital fosters a culture of transparency and continuous improvement. 

Analysis of Sequence of Events, Missed Steps, or Protocol Deviations

To identify the factors that led to this adverse event involving nurse Jane’s medication error, we conducted a root cause analysis. Initially, the event stemmed from the administration of incorrect insulin dosage, which directly affected the patient’s medical management rather than arising from the underlying diabetic condition itself. This deviation suggests a breakdown in the medication administration process and a need for effective strategies to preserve medication safety (Mutair et al., 2021). 

Missed steps and protocol deviations include interruptions during medication preparation and administration, which can lead to distractions and errors (Alteren et al., 2021). These interruptions made nurse Jane overlook the critical step of verifying the dosage against the patient’s medication chart. Additionally, workload, lack of double-checking procedures, and inadequate adherence to medication administration protocols, such as the five rights of medication administration, contributed to the error.  

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

While medication safety measures are essential, effective interprofessional communication could have prevented this event. Efficient communication among healthcare team members ensures an accurate exchange of information, which is crucial for medication to avoid errors and enhance patient outcomes through a shared understanding of treatment plans (Branch et al., 2021). In our case, clear communication between nurses and physicians regarding medication changes and dosage adjustments could have mitigated patient safety risks. Thus, tools like read-back methods and Electronic Health Records (EHR) with alerts for dosage discrepancies will enhance accuracy and reduce errors. Additionally, the adverse event was preventable with enhanced protocols and training emphasizing medication safety.

Implementing strategies such as barcode scanning systems for medication administration (Reale et al., 2023), standardized protocols for double-checking high-risk medications like insulin, and fostering a culture where staff feel empowered to speak up about safety concerns could significantly reduce the likelihood of similar errors (Mutair et al., 2021). However, specific knowledge gaps and areas of uncertainty exist for further improvement in the analysis, such as understanding the particular workflow challenges faced by nurses, existing medication safety protocols within the organization, exploring additional training needs related to medication administration and error prevention strategies, and staff’s level of commitment to change. 

 Quality Improvement (QI) Actions or Technologies 

Several QI interventions and technological advancements are essential to prevent medication errors in healthcare settings. For this incident, suitable actions include robust double-checking procedures and limited interruptions during medication administration. Implementing a double-checking procedure involves two qualified nurses independently verifying the medication, dosage, and administration route before administering the drug to the patient (Jafaru & Abubakar, 2022). This independent checking reduces the risk of errors such as dosage mistakes and medication mix-ups, ensuring patient safety and promoting accuracy in healthcare settings.

Another crucial action is minimizing medication administration interruptions by establishing designated interruption-free zones for medication rounds (Jafaru & Abubakar, 2022). This action can enhance nurses’ focus and reduce distractions, which is critical to prevent errors and ensure nurses are only involved in the medication management process. Simultaneously, implementing Barcode Medication Administration (BCMA) technology is essential to enhance patient safety. BCMA requires nurses to scan the patient’s identification wristband and the medication barcode before administration, ensuring accuracy.

This technology has proven to enhance workflow efficiency, reduce medication errors, and improve patient outcomes (Reale et al., 2023). To evaluate these strategies’ effectiveness, measuring some metrics is crucial. The criteria include staff adherence rates to the action and use of technology, dashboard data for the prevalence of medication errors, reported interruptions during medication administration, improved staff workflow satisfaction, and feedback on the usability and effectiveness of actions and technologies. Regular audits, staff training, and ongoing feedback mechanisms are essential for continuous improvement and sustainability of these initiatives.

Quality Improvement Initiative 

A QI initiative is proposed for our hospital to prevent future medication error incidents. This QI initiative involves implementing double-checking procedures, minimizing interruptions, and introducing BCMA. The steps of the initiative are grounded in the DMAIC (Define, Measure, Analyze, Improve, Control) approach as follows: 

1. The initiative begins by defining the problem and identifying the root causes (Monday, 2022). In our hospital, the problem is medication errors during administration due to interruptions, workload, and lack of adherence to medication administration protocols. 
2. The next step is to quantify the frequency and types of medication errors through incident reports, dashboards, and staff surveys. This step allows the organization to collect baseline data on error rates, protocol adherence, and staff perceptions of workflow challenges.
3. The third step is to analyze the data to identify patterns. Moreover, consider different perspectives from frontline staff regarding malpractices and identify the loopholes within the broader system (Monday, 2022). 
4. Based on the analysis, the organization will implement targeted interventions such as enhancing double-checking procedures, introducing interruption-free medication administration zones, providing additional training on medication safety protocols, and utilizing technology like BCMA to improve accuracy. This step involves planning, procuring, developing, and executing all interventions and materials required to integrate interventions seamlessly (Monday, 2022). 
5. Finally, the organization will establish monitoring systems to track the effectiveness of interventions. Conduct regular audits and feedback sessions to assess compliance with new protocols and gather input from staff on usability and perceived impact (Monday, 2022). 

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

However, some conflicting perspectives regarding the feasibility of implementing new protocols amidst existing workload pressures, resistance to change from staff accustomed to current practices, and varying interpretations of the root causes may persist within the healthcare setting. Therefore, it is essential to address these conflicts by engaging stakeholders from all levels of the healthcare team, fostering open communication, and providing evidence-based rationale for proposed changes. This approach ensures that the initiative is comprehensive, addresses diverse perspectives, and maximizes buy-in and sustainability (Petkovic et al., 2023). Regular reviews and adjustments based on ongoing data analysis and stakeholder feedback are crucial to refining the initiative and improving patient safety outcomes.

Conclusion

In conclusion, medication errors are substantial issues in healthcare settings, impacting patient safety and organizational performance. In a hospital in New York, this issue is highlighted through the case of Mr. Smith, who received extra dosage due to the nurse’s negligence. The root causes of this event were a lack of adherence to standard protocols, interruptions during the medication administration process, and increased workload.

Using strategies like double-checking, interruption-free medication rooms, and BCMA technology, the organization can achieve the desired outcomes and mitigate patient safety risks. A QI initiative using the DMAIC approach is elaborated with a focus on enhancing patient safety through systematic change. While several conflicting perspectives may arise, fostering a culture of continuous improvement and accountability in healthcare settings can effectively mitigate risks and uphold high standards of care.

References

Alteren, J., Hermstad, M., Nerdal, L., & Jordan, S. (2021). Working in a minefield; nurses’ strategies for handling medicine administration interruptions in hospitals – a qualitative interview study. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-07122-8

Branch, J., Hiner, D., & Jackson, V. (2021, March 15). The impact of communication on medication errors. Psnet.ahrq.gov. https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors 

Chirinos, S., Orrego, C., Montoya, C., & Suñol, R. (2023). Relationship between adverse events prevalence, patient safety culture and patient safety perception in a single sample of patients: A cross-sectional and correlational study. BMJ Open, 13(8), e060695–e060695. https://doi.org/10.1136/bmjopen-2021-060695

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

Dahlawi, S., Menezes, R. G., Khan, M. A., Waris, A., & Naseer, M. M. (2021). Medical negligence in healthcare organizations and its impact on patient safety and public health: A bibliometric study. F1000Research, 10(1), 1–15. https://doi.org/10.12688/f1000research.37448.1

Jafaru, Y., & Abubakar, D. (2022). Medication administration safety practices and perceived barriers among nurses: A cross-sectional study in Northern Nigeria. Global Journal on Quality and Safety in Healthcare, 5(1), 10–17. https://doi.org/10.36401/jqsh-21-11

Monday, L. M. (2022). Define, Measure, Analyze, Improve, Control (DMAIC) methodology as a roadmap in quality improvement. Global Journal on Quality and Safety in Healthcare, 5(2), 44–46. https://doi.org/10.36401/jqsh-22-x2 

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46. https://doi.org/10.3390/medicines8090046

Petkovic, J., Magwood, O., Lyubov Lytvyn, Khabsa, J., Concannon, T. W., Welch, V., Todhunter-Brown, A., Palm, M. E., Akl, E. A., Mbuagbaw, L., Thurayya Arayssi, Avey, M. T., Marusic, A., Morley, R., Saginur, M., Nevilene Slingers, Texeira, L., Asma Ben Brahem, Bhaumik, S., & Imad Bou Akl. (2023). Key issues for stakeholder engagement in the development of health and healthcare guidelines. Research Involvement and Engagement, 9(1). https://doi.org/10.1186/s40900-023-00433-6 

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

Reale, C., Ariosto, D., Weinger, M. B., & Anders, S. (2023). Medication safety amid technological change: Usability evaluation to inform inpatient nurses’ electronic health record system transition. Journal of General Internal Medicine, 38, 982–990. https://doi.org/10.1007/s11606-023-08278-1