Adverse Effects or Near Missed Analysis
Write a comprehensive analysis (5-7 pages) of an adverse event or near miss from your nursing experience. Integrate research and data on the event to propose a quality improvement (QI) initiative to your current organization.
For this assessment, you will prepare a comprehensive analysis on an adverse event or near miss that you or a peer experienced during your professional nursing career. You will integrate research and data on the event and use this information as the basis for a quality improvement (QI) initiative proposal in your current organization.
The following points correspond to the grading criteria in the scoring guide. The subbullets under each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your adverse event or near-miss analysis addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels relating to each grading criterion.
Analyze the missed steps or protocol deviations related to an adverse event or near miss.
Describe how the event resulted from a patient’s medical management rather than from the underlying condition.
Identify and evaluate the missed steps or protocol deviations leading to the event.
Explain the extent to which the incident was preventable.
Research the impact of the same type of adverse event or near miss in other facilities.
Analyze the implications of the adverse event or near miss for all stakeholders.
Evaluate the short- and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze each stakeholder’s contribution to the event.
Analyze the interprofessional team’s responsibilities and actions. Explain what measures each interprofessional team member should have taken to create a culture of safety.
Describe any change to process or protocol implemented after the incident.
Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
Analyze the quality improvement technologies put in place to increase patient safety and prevent recurrence of the near miss or adverse event.
Determine the appropriateness of the technology application for a specific patient or situation.
Research scholarly, evidence-based literature to learn how institutions can integrate solutions to prevent similar events.
Incorporate relevant metrics of the adverse event or near-miss incident to support need for improvement.
Identify the salient data associated with the adverse event or near miss that is generated from the facility’s dashboard.
Note: Dashboard means data generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management.
Analyze what the relevant metrics show.
Explain research or data related to the adverse event or near miss that is available outside of your institution. Compare internal data to external data. Use resources such as the Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Institute for Healthcare Improvement (IHI), and the World Health Organization (WHO).
Outline a quality improvement initiative to prevent the recurrence of an adverse event or near miss.
Explain, from an evidence-based viewpoint, how your facility now manages or should manage the process or protocol.
Evaluate how other institutions addressed similar incidents or events.
Analyze QI initiatives developed to prevent similar incidents. Explain why they are successful. Provide evidence of their success.
Propose solutions for your selected institution that can be implemented to prevent similar future adverse events or near-miss incidents.
Communicate analysis and proposed initiative in a professional, effective manner, writing content clearly and logically, with correct use of grammar, punctuation, and spelling.
Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.
Adverse Effects or Near Missed Analysis
A near miss experience involves an experience that could have led to an adverse patient outcome but did not. Such as event results from medical errors. Medication errors are most common types of medical errors in health facilities yet they are preventable. A facility can utilize various strategies including use of technology to prevent the errors. The discussion will focus on a near miss experience in my nursing experience, an analysis of the missed steps, stakeholders involved, the role of interprofessional team, and a quality improvement initiative to address the issue.
The Near Missed Experience
A near miss experienced in my nursing career involved a patient that was prescribed cetirizine but a nurse’s administered sertraline. One morning after starting my shift, a patient complained of itching, nausea, and dizziness. Her face appeared a bit swollen. Checking on their chart, the prescribed medications seemed right based on their medical history. Based on the information provided by the patient, the symptoms developed after receiving their last medication, which according to them was an hour ago. The records however indicated that their last medication was administered seven hours ago. Upon checking their cabinet one medication did not match the prescription in the medical records. Sertraline was available in the drawer and was not prescribed while cetirizine was prescribed and not available in the drawer. The nurse admitted that they did not confirm whether the pharmacy delivered the right medication since the name of the patient was visible on the prescription. The nurse that ordered the prescription confirmed that they ordered the right medication only for the pharmacist to admit that the nurse’s pronunciation for cetirizine sounded like sertraline.
An Analysis of Missed Steps and Deviations Related to the adverse Event
The event resulted from patient management and not the underlying conditions. The reported and observed symptoms including nausea, dizziness, itching, and swelling were side effects of the sertraline. The patient had been admitted due to a respiratory tract infection and an allergic reaction. Although the patient had suffered an allergic food reaction, the patient has made significant progress especially in symptom reduction.
There are various missed steps relating to the adverse event. The nurse that administered sertraline failed to confirm from the medical records whether the delivered prescription was right. The nurse also failed to update the medical records after administering sertraline and admitted to planning updating after the shift was over as they wanted to attend to other patients. The nurse that ordered the prescription used an informal way of communication, which led to confusion. Communication involving ordering of prescriptions in the facility is mainly through emails and messages. The medication error would have been prevented if the nurses followed the existing protocols including confirmation of prescriptions before administration and use of formal communication which would have prevented delivery of wrong medication due to mispronunciation. Use of barcodes would also have eliminated the error completely.
The Impact of the Same Type of Adverse Event in other Facilities
Research indicates that approximately 400 000 hospitalized patients are exposed to a type of preventable harm while an estimate of 100,000 patients dies every year due to medical errors in hospitals and clinics (Rodziewicz et al., 2021). The impact of the near miss event on the stakeholders varies depending on the role of the stakeholder in ensuring patient safety. The patients suffer harm due to medication errors and may suffer long-term effects as disabilities. In the case shared, the patients suffered nausea, dizziness, itching, and swelling. Although the patient was to be released that afternoon, their hospital stay was prolonged to the next day. The family suffers inconvenience and may incur additional costs related to extra care to the patient. The interprofessional teams may suffer malpractice claims. According to Rodziewicz et al. (2021), health professionals may suffer damage in their confidence and morale, malpractice claims, and experience psychological effects such as guilt, fear, and depression. In the case of near miss event, the involved nurses and the pharmacist did not suffer and ethical or legal consequences as no major damage occurred. The nurses however suffered guilt and disciplinary actions from the facility. The facility was at the risk of suffering malpractice claims and extra costs if the patient suffered an adverse event and sued the facility. Long-term effects may include a bad public image and a decrease in patients seeking care. The community risk to suffer from mistrust and reduced confidence in the capacity of the facility to provide safe care.
The Interprofessional Team’s Responsibilities and Actions
Interprofessional teams comprises of members from two or more professions including nurses, pharmacists, physicians, social workers, and others. Studies indicate that the effectiveness of the interprofessional teams is based on effective communication (Busari et al., 2017). Effective communication facilitates problem-solving, decision making through sharing of ideas and embracing complementary roles. Major professionals in this case include the physician, the nurses, and the pharmacists. The nurses should have adhered to procedures and guidelines in ordering and administering medication. This includes sending the pharmacists an email indicating required prescription, confirming prescription upon arrival, and updating the patients’ medical records after administering the medication. The pharmacists should have requested for a written order of the prescription to minimize chances of a medication error. The physician had done their part by making the right prescription but should function more as role models in maintaining a culture of safety.
Change to Process or Protocol Implemented After the Incident
Various changes were made to increase patient safety in relation to drug administration. One of the policies implemented required pharmacists to only dispense after obtaining a prescription from an authorized prescriber. Communication involving prescription was also limited to limited to written communication. The facility also made a long-term plan of implementing a system that enhances scanning of medication before dispensing and before administering.
Medication errors have become a major concern in hospitals as the numbers are significantly high. An estimate of 7000 deaths occurs every year to medication errors, while 30% of the patients affected are more likely to die or become disable for than six months (Gorgich et al., 2016). The errors are common among nurses and students but the reporting is low. The numbers may therefore be higher than the indicated hence the need for quality improvement. In the country the estimated cost of medication errors is 6.1 to 6.5 billion dollars (Gorgich et al., 2016). The facility where the near miss event occurred reported a minimum of 3 medication errors with one case having a high likelihood of causing severe harm to the patient. According to the World Health Organization (2016), medications errors are a health care concern and have suggested use of technology to prevent the errors. According to the Centers for Disease Control and Prevention, ADEs results to 1.3 million visits to the emergency room and 350 000 hospitalizations annually. 40%of costs related to adverse events can be prevented (Centers for Disease Control and Prevention, 2010). The quality improvement technology for reducing the risk and increasing safety is the barcode medication administration technology. The technology is appropriate as it automates the verification process by scanning of medication barcodes and the patient’s wristband. The technology is effective especially when the identity of the patient, dosage, and prescription is not well known by the profession. Evidence-based solution to medication errors include adoption of barcode technology and electronic medication administration the efficiency of barcode medication administration system (Naidu & Alicia, 2019).
A Quality Improvement Initiative to Prevent the Recurrence of an Adverse Event or Near Miss
A quality improvement initiative to prevent the recurrence of the near miss experience involves establishing a culture of safety and implementing the necessary technology. According to Rodziewicz et al (2021), one step of making improvements is fighting a culture of blame, punishment, and shame and establishing a culture of viewing medical errors as challenges that should be overcomes. Another initiative is use of barcode in medication. Studies shows that an organization should re-engineer a work process and workflow changes prior to adopting and implementing new technology (Naidu & Alicia, 2019). Majority of the health care institutions have addressed the medication errors through barcode medication systems. More than 58% of hospital in the country have implemented BCMA technology which has shown the potential to reduce administration errors by 50% and serious medication errors by 25% (Truitt et al., 2016). Proposed solutions for the facility include adoption and implementation of the barcode technology and electronic medication administration. The technology should be accompanied with the proper organizational infrastructure that include culture, workflow, and work process changes.
Medication errors are a great threat to the quality and safety of care provided to patients yet they are preventable. It is the responsibility of the facility and health care professionals to address the issue. In the near miss experience shared, the patient did not suffer severe effects. The side effects were mild. In other cases, a patient may suffer disability or die due to severity of the medication error. Proposed solution include use of BCMA technology and an organizational culture positive towards the errors and champions reporting of the errors.
Busari, J. O., Moll, F. M., & Duits, A. J. (2017). Understanding the impact of interprofessional collaboration on the quality of care: A case report from a small-scale resource limited health care environment. Journal of multidisciplinary healthcare, 10, 227. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5472431/
Centers for Disease Control and Prevention. (2010). Medication Safety Program. Retrieved from https://www.cdc.gov/medicationsafety/index.html
Gorgich, E. A. C., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global journal of health science, 8(8), 220. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016359/
Naidu, M., & Alicia, Y. L. Y. (2019). Impact of bar-code medication administration and electronic medication administration record system in clinical practice for an effective medication administration process. Health, 11(05), 511. https://www.scirp.org/html/6-8204580_92509.htm
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical error reduction and prevention. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499956/
Truitt, E., Thompson, R., Blazey-Martin, D., Nisai, D., & Salem, D. (2016). Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events. Hospital pharmacy, 51(6), 474-483. https://journals.sagepub.com/doi/abs/10.1310/hpj5106-474
World Health Organization. (2016). Medication Errors. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf