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

Student Name

Capella University

NURS-FPX 6016 Quality Improvement of Interprofessional Care

Prof. Name:

Date

Adverse Event or Near Miss Analysis

In the health care setting, adverse events or near misses both affect patient safety and the standard of care. An adverse event is an unintentional damage to a patient caused by a missing act in patient care procedures, and it has nothing to do with the patient’s actual medical condition. A near-miss occurrence has the potential to damage patients, but due to early action, no adverse events occur (Yang & Liu, 2021). Adverse events can be fatal. More than 250,000 people experience adverse effects, with 100,000 fatalities. The incidence of adverse events in medical facilities is generally between 2.9% and 16.6%, with avoidable mistakes varying from 1.0% to  8.6% (Zanetti et al., 2021). In the assessment, an adverse event analysis will be undertaken for a patient who encountered an Adverse Drug Event (ADE) in the Henry Ford Hospital.

Comprehensive Analysis of Adverse Event

During my nursing practice, I witnessed when my fellow nurse, Amelia, committed a mistake that led to an adverse event. She also faced a financial penalty. Last week, Amelia was assigned to care for a patient named Jennifer. She was hospitalized in the Henry Ford Hospital due to suffering from Gastroenteritis. She was admitted to the hospital for the last three days. During our shift, Jennifer complained of gastric pain and feeling dizziness, and nausea. I asked Amelia to call the doctor, and he verbally prescribed and guided Amelia about the medication named Metoclopramide to Jennifer.

Due to the high workload and staffing shortage, Amelia was stressed. She, carelessly and without medication reconciliation, administered Metoprolol drug to Jennifer instead of Metoclopramide. Me and my colleague observed that Jenniffer’s health worsened due to the wrong drug administration. She has a rash allergy and has difficulty in breathing. Upon investigation, it is found that this ADE occurred due to Amelia’s mistake. Jennifer’s family was informed about this ADE and her condition. I witnessed this complex event that prompted the nurse manager and hospital management to investigate adverse medication events further in their hospital to ensure the safety of patients and Quality Improvement (QI). 

Implications of Adverse Event for Relevant Stakeholders

Adverse events in healthcare necessitate the planning, development, decision-making, financial support, and implementation of solutions by a multi-professional team and diverse stakeholders to ensure patient safety and QI. In Jennifer’s case, the Medication Administration Error (MAE), resulted in an ADE. It has several implications for particular stakeholders, such as the patient and her family, nurses, and management. In the Henry Ford Hospitalthe adverse incident has a detrimental influence on Jennifer and her family. ADE has substantial emotional, economic, physical, and socio-behavioral effects on patients and significantly diminishes trust and readiness to accept healthcare (Prentice et al., 2020). Numerous medical interventions significantly altered the patient’s standard of life.

Jennifer’s family members faced emotional difficulty as they witnessed their loved one need further therapy due to ADE. They were dissatisfied with hospital administrators and caregivers who were unable to provide appropriate patient care. After the ADE, the nurse in charge of the unit experienced professional difficulty, negative emotional consequences, and legal action. Furthermore, the nursing staff stressed correcting gaps in patient safety protocols and preventing future tragedies (Mahat et al., 2022). Lastly, the hospital administration faced reactions from patients’ family members, resulting in a drop in reputation, lower patient volume, and monetary repercussions (Ozeke et al., 2019). 

Adverse patient outcomes entail consequences for medical professionals, hospital administrators, and legislators. Nurses and physicians are primarily responsible for providing quality treatment to their patients utilizing established clinical practices, particularly in terms of medication safety (Bello, 2021). Nurse leaders must ensure that each staff member has a thorough understanding of medication safety best practices. Furthermore, management and legislators must set regulations for safe medicine delivery that ensure patients’ safety is not compromised. Moreover, administrators should initiate educational and training sessions to make nurses aware and equip them with the abilities and skills to adhere to safe drug administration protocols (Park & Han, 2023).

Assumptions

This analysis assumes that patient health is the first concern for medical personnel, including nurses, and efficient procedures are required to ensure Jennifer’s safety (Prentice et al., 2020). It is assumed that medical staff, particularly nurses, provide high-quality care while protecting patient safety and fulfilling their ethical obligations. An expanding proportion of errors and adverse occurrences causes mental stress among healthcare personnel, resulting in additional issues for both patients and the health staff.  Negative outcomes and errors constitute a component of the medical system; however, stakeholders need to work together efficiently to reduce ADEs and enhance the standard of life (Mahat et al., 2022).

Analysis of Sequences of Events, Missed Steps, and Protocol Deviations

The Henry Ford Hospital’s administration conducted a thorough root-cause analysis to better comprehend the cause of Jennifer’s adverse condition. The patient, Jennifer, was supervised by my nurse fellow, Amelia, who was assigned a higher number of patients, and she was overworked and understaffed. Due to work stress, she administered the wrong medication carelessly, which is Metoprolol instead of Metoclopramide, to Jennifer. The root causes of ADE are stress, workload, staff shortage in the hospital, and not adherence to safety protocols (Ayre et al., 2023).

The missing steps and protocol variation encompass an absence of medicine administration protocols. The nurse did not observe the five rights of drug delivery. The nurse must be educated on the appropriate patient, drug, dosage, route, and time. Deviating from each of the rights can result in significant MAEs and negative consequences (Spanakis et al., 2020). Due to a lack of knowledge of drug administration protocol, my nurse fellow administered the wrong drug without considering the five rights of medicine, which ultimately resulted in ADE. Furthermore, lack of following the medication reconciliation technique. Medication safety recommendations were not adequately implemented, indicating insufficient training and compliance with standard protocols by medical staff (Park & Han, 2023).

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

One of the reasons for the medication error adverse event for Jennifer is that Amelia was in a hurry and she did not consider reconciling drugs and administered the wrong drug to Jennifer, leading to severe side effects. There was also a demand for improved communication routes between nurses and patients to facilitate timely responses to critical health requirements. Except in an emergency event, it is strictly prohibited to follow verbal prescriptions in medical settings. To avoid errors in drug prescription and delivery, the nurse should not follow the doctor’s verbal command. Paper-based drug prescriptions reduce drug errors and improve patient outcomes (Sendlhofer et al., 2019).

If the doctor has prescribed the medication in written form, it can aid my fellow Amelia in understanding the prescription better. Ultimately, it can avoid adverse events. Lastly, in the event of a staff shortage, the nurse should notify their supervisor so that such acts do not jeopardize the safety of the patients. By hiring more staff, the burden of nurses like Amelia can be reduced, and she can offer efficient care to patients by mitigating such events. Nurse managers should design regulations and procedures to deliver efficient care without compromising patient safety (Harton & Skemp, 2020). 

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

Although the analysis identified the leading causes of the adverse event, there are specific gaps in knowledge and areas of uncertainty that demand additional information for comprehensive analysis. More information is required to determine whether the patient, like Jennifer’s medical history, can give an understanding of their level of risk. Moreover, why was the doctor unaware of the policy regarding verbal prescriptions? Why did the nurse manager not manage the understaffed situation? What function did the administration perform in this situation? More information will make conducting a thorough and coordinated adverse event evaluation easier.

Quality Improvement Actions and Technologies

Several QI strategies and technologies are examined to be employed within Henry Ford Hospital to lower the likelihood of ADE caused by MAE. Strategies include adopting a comprehensive medication delivery protocol, providing medication safety education, and developing technological interventions. The incident happened because of a lack of safety protocol; a comprehensive medication administration protocol must be implemented.

It includes compliance with the five rights of drug delivery, double checking, and medication reconciliation guidelines must be established (Sharon et al., 2024). By providing adequate education to nurses, including Amelia, become aware of standard drug delivery guidelines. Conducting training sessions, including comprehension activities like simulation-based exercises, improves the capabilities of Amelia and other nursing staff. It will aid in avoiding such ADE in the future. Another QI practice advocated is to avoid verbal prescriptions. According to the research, verbal orders should be avoided wherever feasible and should only be used in extreme circumstances, such as an emergency. Every hospital, including Henry Ford Hospital, should create a policy to omit verbal prescriptions to maintain medication safety (Ambwani et al., 2019).

Moreover, medication safety training and education for nurses is a vital action for QI. Nursing personnel acquire knowledge and confidence in recognizing the circumstances in which MAE arises and applying theoretical knowledge in practice to fix them. High-fidelity models and problem-oriented instruction have a crucial impact on lowering ME and improving patient safety for Jennifer (Park & Han, 2023). 

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

Integration of technology is critical for improving QI and lowering ADE due to MAE. The Bar-Coded Medication Administration (BCMA) system can reduce ADE while also improving pharmaceutical safety. The BCMA ensures that nurses provide the right drugs by scanning the patient and drug barcodes. BCMA system is based on pharmaceutical rights and prevents human mistakes (Grailey et al., 2023). This approach enables nurses in Henry Ford Hospital to follow patient safety regulations. BCMA contributed to a 41% decline in ME and 51% in potential ADEs (Küng et al., 2021). Furthermore, an Electronic Health Record (EHR) system will be implemented.

The EHR improves the documentation and interaction between medical practitioners, eliminates misunderstanding and misinterpretation, and speeds up care delivery. It includes allergy documentation and medication reconciliation features, which help to reduce ADEs associated with MAE. Reconciliation tools in EHR systems can reduce drug mistakes by more than 50% (Eisa & Bah, 2022). The effective implementation of these technologies is possible through interdisciplinary collaboration. Collaboration of nurse informaticists, IT professionals, and other medical staff, including nurses, aid in employing EHR and BCMA systems. Through EHR, nurses like Amelia can coordinate with physicians and reconcile drugs with digital prescriptions, making the drug delivery process efficient.

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

Similarly, using bar code scanning, Amelia can scan the barcode of medication and patient bracelet, which mitigates the chances of ADE.After implementing the strategies, it is critical to assess their success. Henry Ford Hospital should use measuring tools to assess the success of QI actions by comparing MAE and ADE rates before and after the intervention. Cost reductions as a result of strategic implementation. Improvements in nurses’ medication safety abilities can be assessed by surveys and feedback (Craig et al., 2021). The hospital collected data on the rate of MAE incidents, which exceeded the benchmark, which is the rate of 52 medication errors per 100 hospitalizations (Thomas et al., 2020).

These statistics point to the need for advancement in preventing ME rates in Henry Ford Hospital. Learning from other organizations’ experiences by benchmarking and collaboration can offer helpful knowledge into best practices for avoiding such incidents. Other healthcare organizations have used similar technologies, such as EHR, which has built-in medication reconciliation and alarm functionalities. These hospitals also conducted monthly audits to uncover risk factors and address them immediately to prevent ME. They have additionally created multidisciplinary MAE prevention groups to examine incidences and identify possibilities for reform to prevent future ADE difficulties (Eisa & Bah, 2022).

Outline for a Quality Improvement Initiative

The MAE led to the ADE occurring due to the quick delivery of medication to Jennifer without following guidelines. As a result, Jennifer required prompt and appropriate care to effectively overcome the adverse effects of the wrong medicines. To address MAE-related ADEs in the future in Henry Ford Hospital, a QI initiative that can be effectively implemented is to establish standard patient safety and medication practices protocols and guidelines for the safe delivery of drugs (Sharon et al., 2024). For this purpose, multidisciplinary team members comprising nurses, pharmacists, doctors, and QI personnel will coordinate and collaborate to develop a toolkit for avoiding MAE.

Moreover, training and medication safety education will be offered to medical staff, including nurses, to improve drug safety knowledge and make them aware of adverse consequences associated with the wrong medication (Park & Han, 2023). The evidence of Kim and  Lee (2020), asserted that Medication Error Encouragement Training (MEET) improves nurses’ confidence by bringing them face-to-face with possible MAE in a secure setting. It aids in enhancing their capabilities to avoid ADE during practice. Other QI initiatives encompass the integration of BCMA and the EHR system to improve the drug delivery process (Grailey et al., 2023). The research conducted by Owens et al. (2020), highlighted the effectiveness of the BCMA system in reducing MAEs related ADEs.

The findings showed that the wrong dosage error rate decreased from 2.96% to 0.76%, improving patient safety. Moreover, the study of Eisa and Bah (2022), showed that implementing an EHR system is crucial to avoid medication errors. Findings showed that the average number of pharmaceutical errors decreased significantly, from 22.76 to 18.76, by implementing the EHR system in  Royal Commission Hospital. These initiatives are crucial for improving patient safety by guiding nurses to comply with standard protocols and the use of technology. However, a lack of interdisciplinary collaboration and financial resource limitations can impact the efficacy of the QI initiative (Sharon et al., 2024).

Conclusion 

Henry Ford Hospital faces challenges in improving care quality and patient safety, particularly medication safety.  Medication safety can be improved by increasing staff knowledge and education and implementing policies to eliminate ADEs. QI measures, including standard protocols and nurse training, will help reduce these errors. Furthermore, successful collaboration and interaction are vital for improving patient safety and QI.

References

Ambwani, S., Misra, A. K., & Kumar, R. (2019). Medication errors: Is it the hidden part of the submerged iceberg in our health-care system?. International Journal of Applied and Basic Medical Research9(3), 135-142. https://doi.org/10.4103%2Fijabmr.IJABMR_96_19

Ayre, M. J., Lewis, P. J., Phipps, D. L., & Keers, R. N. (2023). Understanding the causes of medication errors and adverse drug events for patients with mental illness in community care (DISCOVER): A qualitative study. Frontiers in Psychiatry14https://doi.org/10.3389/fpsyt.2023.1241445

Bello, C. B. (2021). Adherence to medication administration guidelines among nurses in a health facility in South-West Nigeria. Pan African Medical Journal40(1). https://doi.org/10.11604%2Fpamj.2021.40.56.27562

Craig, S. J., Kastello, J. C., Cieslowski, B. J., & Rovnyak, V. (2021). Simulation strategies to increase nursing student clinical competence in safe medication administration practices: A quasi-experimental study. Nurse Education Today96, 104605. https://doi.org/10.1016/j.nedt.2020.104605

Eisa, M., & Bah, S. (2022). Impact of implementing electronic health records on medication safety at an HIMSS stage 6 hospital: The pharmacist’s perspective. The Canadian Journal of Hospital Pharmacy75(4), 267–275. https://doi.org/10.4212/cjhp.3223

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

Grailey, K., Hussain, R., Wylleman, E., Ezzat, A., Huf, S., & Bryony Dean Franklin. (2023). Understanding the facilitators and barriers to barcode medication administration by nursing staff using behavioural science frameworks. A mixed methods study. BioMed Central Nursing22(1). https://doi.org/10.1186/s12912-023-01382-x

Harton, L., & Skemp, L. (2022). Medical–surgical nurse leaders’ experiences with safety culture: An inductive qualitative descriptive study. Journal of Nursing Management30(7), 2781-2790. https://doi.org/10.1111%2Fjonm.13775

Kim, K., & Lee, I. (2020). Medication error encouragement training: A quasi-experimental study. Nurse Education Today84, 104250–104250. https://doi.org/10.1016/j.nedt.2019.104250

Küng, K., Aeschbacher, K., Rütsche, A., Goette, J., Zürcher, S., Schmidli, J., & Schwendimann, R. (2021). Effect of barcode technology on medication preparation safety: A quasi-experimental study. International Journal for Quality in Health Care33(1). https://doi.org/10.1093/intqhc/mzab043 

Mahat, S., Rafferty, A. M., Vehviläinen-Julkunen, K., & Härkänen, M. (2022). Negative emotions experienced by healthcare staff following medication administration errors: A descriptive study using text-mining and content analysis of incident data. BioMed Central Health Services Research22(1), 1474. https://doi.org/10.1186%2Fs12913-022-08818-1

Owens, K., Palmore, M., Penoyer, D., & Viers, P. (2020). The effect of implementing bar-code medication administration in an emergency department on medication administration errors and nursing satisfaction. Journal of Emergency Nursing46(6), 884–891. https://doi.org/10.1016/j.jen.2020.07.004

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

Ozeke, O., Ozeke, V., Coskun, O., & Budakoglu, I. I. (2019). Second victims in health care: Current perspectives. Advances in Medical Education and Practice, 593-603. https://doi.org/10.2147/AMEP.S185912

Park, J., & Han, A. Y. (2023). Medication safety education in nursing research: Text network analysis and topic modeling. Nurse Education Today121, 105674–105674. https://doi.org/10.1016/j.nedt.2022.105674

Prentice, J. C., Bell, S. K., Thomas, E. J., Schneider, E. C., Weingart, S. N., Weissman, J. S., & Schlesinger, M. J. (2020). Association of open communication and the emotional and behavioural impact of medical error on patients and families: State-wide cross-sectional survey. British Medical Journal Quality & Safety29(11), 883–894. https://doi.org/10.1136/bmjqs-2019-010367

Sendlhofer, G., Pregartner, G., Gombotz, V., Leitgeb, K., Tiefenbacher, P., Jantscher, L., Richter, C., Hoffmann, M., Kamolz, L. P., & Brunner, G. (2019). A new approach of assessing patient safety aspects in routine practice using the example of “doctors handwritten prescriptions.” Journal of Clinical Nursing28(7-8), 1242–1250. https://doi.org/10.1111/jocn.14736

Sharon, Eikenhorst, L. V., Vonk, A. S., Bernadette C.F.M. Schutijser, & Wagner, C. (2024). Evaluating deviations and considerations in daily practice when double-checking high-risk medication administration: A qualitative study using the FRAM. Heliyon10(4), e25637–e25637. https://doi.org/10.1016/j.heliyon.2024.e25637

Spanakis, M., Patelarou, A. E., & Patelarou, E. (2020). Nursing personnel in the era of personalized healthcare in clinical practice. Journal of Personalized Medicine10(3), 56. https://doi.org/10.3390/jpm10030056

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

Thomas, B., Pallivalapila, A., Kassem, W. E., Hail, M. A., Paudyal, V., McLay, J., MacLure, K., & Stewart, D. (2020). Investigating the incidence, nature, severity and potential causality of medication errors in hospital settings in Qatar. International Journal of Clinical Pharmacy43(1), 77–84. https://doi.org/10.1007/s11096-020-01108-y

Yang, Y., & Liu, H. (2021). The effect of patient safety culture on nurses’ near-miss reporting intention: The moderating role of perceived severity of near misses. Journal of Research in Nursing26(1-2), 6–16. https://doi.org/10.1177/1744987120979344

Zanetti, A. C., Dias, B. M., Bernardes, A., Capucho, H. C., Balsanelli, A. P., Moura, A. A., Soato, R., & Gabriel, C. S. (2021). Incidence and preventability of adverse events in adult patients admitted to a Brazilian teaching hospital. PLOS ONE16(4). https://doi.org/10.1371/journal.pone.0249531 

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