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 and near-miss events are relevant yet distinguished from each other, both impacting patient safety and health outcomes. They result in unintended patient harm due to committing or omitting certain acts. These adverse events can be patient falls, medication errors, complications during treatment, etc. On the other hand, near-miss events can potentially harm patients but do not result in injuries or damage. They are seen as opportunities to learn and improve patient safety to prevent the incidence of similar events in the future (Azadegan et al., 2019).

This paper highlights an analysis of adverse events at North American Specialty Hospital where a patient expired as a result of a medication error and created chaos in the healthcare organization. The assessment will highlight the implications of the adverse event for relevant stakeholders. Furthermore, missed steps and deviations from protocols will be analyzed later in this assessment. Lastly, a quality initiative will be outlined to prevent future adverse events and near misses.

Comprehensive Analysis of Adverse Events Due to Medication Error

The patient, Julia, was in the Intensive Care Unit (ICU) after a severe cardiac event. The medical team worked diligently to stabilize him, and his fluctuating condition required careful monitoring and adjustment in his medication regimen. The patient’s physician prescribed a medication dosage change to address the continuously evolving condition. However, due to the chaotic environment, work burnout among nurses, and lack of communication protocols, the nurse on duty forgot to update the patient’s medication chart dosage. Consequently, the nurse on the next shift administered the patient the outdated dosage of heart medication. The insufficient medication failed to address the worsening of the cardiac status of Julia. Ultimately, the patient reached a critical point when the medical team rushed upon calling and failed to save the patient’s life.

Implications of Adverse Event for Relevant Stakeholders

The incidence of adverse events impacts patient safety and affects stakeholders, including family members, healthcare professionals, administration, and organizations (Elliott et al., 2021). In Julia’s case, all these stakeholders were greatly influenced, resulting in adverse outcomes. The adverse event of medication error due to the wrong dose led to the patient’s death, resulting in a direct impact on the patient due to sudden loss of life. Moreover, it caused immense grief and emotional trauma for the family. Julia’s children were greatly influenced and were emotionally stressed and grieved. This incident also eroded their trust in the healthcare system. The long-term effects included disturbed mental health and the inability of the family to process usually in a mundane routine, impacting their work and personal life (Rodziewicz & Hipskind, 2020).

 Furthermore, healthcare professionals, specifically nurses, faced massive trouble due to being the responsible parties. Moreover, the clinicians were shocked as the poor communication among interdisciplinary teams resulted in such lethal adverse events (Wu et al., 2020).  In Julia’s case, the nurse who ended her shift without updating the changed dosage encountered significant repercussions. The legal implications of litigation caused damage to their professional reputation and financial instability. The nurse who did not update the patient’s medication charge was fined a heavy financial penalty, causing emotional distress and poor mental health (Mahat et al., 2022). Lastly, the hospital faced legal and financial consequences due to raised legal proceedings.

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

Additionally, it alleviated the hospital’s reputation, and patient flow was significantly reduced due to eroded public trust and poor-quality care treatments. This incident resulted in changes in policy and the initiation of quality improvement initiatives to improve the efficiency of healthcare (Alomari et al., 2020). The communication gap was significantly reduced as a result of this adverse event. The long-term effects were improved workflows, enhanced interprofessional collaboration, and better-quality care treatments delivered to patients (Kavanagh & Donnelly, 2020).

Assumptions

The analysis on which this analysis is based includes that medication errors have the potential to cause patient harm to the extent of causing death. Furthermore, the patients requiring emergency care are prone to medication errors and require intricate care to provide better care. Another assumption emphasizes that a limited number of nursing staff causes work burnout and potentially causes medication errors (Rodziewicz & Hipskind, 2020).

Sequences of Events, Missed Steps/ Protocol Deviations

The Root-Cause analysis (RCA) was conducted to track Julia’s case’s sequence of events and missed steps. The adverse event of medication error took place due to poor medical management processes, specifically in communication and implementation of changes to the patient’s medication regimen. The patient’s physician prescribed a crucial adjustment in heart medication dosage due to the evolving patient’s condition. The nurse who obtained this prescription was about to end her shift and, due to continuous work strain, forgot to update the medication chart and failed to convey this information to the coming nurse on the following shift (Montgomery et al., 2020).

The breakdown in communication overburdened nurses due to hectic schedules, which led to fragmented care. The new nurse on shift was also unaware of the changed dosage and administered an outdated dosage. Literature also highlights that nurses who are worn out due to hectic schedules are at risk of making medication errors due to poor communication and mindfulness (Melnyk et al., 2021). The nurse on duty was supposed to update the medication chart and add notes for the nurse on the next shift to deliver new information effectively. However, she forgot to do so due to continuous work and burnout, failing to disseminate the changed dosage information to other nursing staff (Montgomery et al., 2020).

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

The knowledge gaps and missing information, such as how many nurses were actively working in the overall hospital and ICU unit and reasons for nurse work burnout, required further information (Kwon et al., 2021). Why did the nurse not verbally communicate with the staff on the next shift before ending her shift? Why was the hospital administration not aware of the hectic and complex work schedule of nurses, and why was it not proactively working to ensure adequate nursing staff to maintain workflow balance and job satisfaction among nurses? These unanswered questions could improve the analysis by providing additional information. 

Quality Improvement Actions/ Technologies

The literature has emphasized using innovative technologies and principles of safe medication administration (Gildon et al., 2019). The technologies include Electronic Health Records (EHRs), which facilitate advanced decision support and streamlined communication without the need for verbal communication among interdisciplinary team members. The EHRs support capabilities that provide time alerts, notifications, and a bird’s eye view of patient’s health and medical information (Adams et al., 2021). As the physician prescribes medication or changes to dosage, healthcare professionals can be notified about these changes, and potential medication errors can be reduced. This ultimately enhances patient safety and reduces patient harm (Adams et al., 2021).

Other quality improvement actions include structured communication protocols during shift changes to ensure that critical information can be effectively communicated. Through hands-off communication, the chances of medication errors are reduced, and patient safety can be facilitated (Carver et al., 2019). Lastly, the hospital administration must monitor the nurse-to-patient ratio to prevent staff burnout and medication errors due to these events. An adequate number of nurses will allow them to work efficiently with absolute mindfulness, a crucial element in nursing practices (Rangachari & L. Woods, 2020).

Consequently, adverse events like medication errors can be avoided. Different criteria can evaluate the integration of these technologies and actions. For instance, the efficacy of these actions and technologies is evaluated by comparing the number of medication errors before and after implementing them. When the number is significantly low post-implementation, the success of these actions and technologies is evident. Likewise, patient satisfaction can be analyzed to evaluate the effectiveness of these actions and technology (Nurmeksela et al., 2021).

Quality Improvement Initiative Outline

The adverse event occurred to Julia, who was monitored by a nurse on the evening shift who administered outdated medication when the patient’s condition started to fluctuate. The patient was unable to breathe and suddenly went into cardiac arrest. Upon seeing her vitals, the nurse rushed to call medical staff, and the hospital administration monitored the incident thoroughly. This called for integrating quality improvement technologies and policy amendments to promote quality improvement actions (Alomari et al., 2020). For this purpose, a technology-based quality improvement initiative is designed for North American Specialty Hospital. Integrating and implementing EHRs to initiate quality improvement will help prevent future medication errors (Colquhoun et al., 2020). 

The EHRs ensure seamless patient health and medical data management, including prescription and related changes, administration records, and other features such as patient allergies. This prevents potential medication interaction and dosage errors as EHRs provide real-time alerts and notify healthcare professionals upon making any changes. This virtual communication is enhanced through EHR and facilitates timely updates to prevent errors due to poor communication (Devoe et al., 2019).

The conflicting data and perspectives include concerns related to data accuracy within EHRs. This requires auditing data regularly and evaluating the reliability of medication-related information (Alami et al., 2020). Moreover, healthcare staff can also show potential resistance to adopting new EHR technology and implementing change management strategies. This requires additional training to address usability issues and encourage buy-in to use this technology effectively (González, 2022).

Conclusion

Julia, a heart patient, was unable to survive due to a medication error of the wrong dosage. This resulted in emotional distress for the family, nurses, and healthcare team. Moreover, the organization bore the negative repercussions of this adverse event. The adverse event took place due to work burnout in nurses, followed by forgetfulness to update the medication chart of the patient. The EHR and communication protocols are effective strategies to initiate quality improvement. The outlined QI initiative suggested for this hospital is the integration and implementation of EHR within the organization.

 References

Adams, K. T., Pruitt, Z., Kazi, S., Hettinger, A. Z., Howe, J. L., Fong, A., & Ratwani, R. M. (2021). Identifying health information technology usability issues contributing to medication errors across medication process stages. Journal of Patient Safety, 17(8). https://doi.org/10.1097/pts.0000000000000868 

Alami, H., Lehoux, P., Gagnon, M.-P., Fortin, J.-P., Fleet, R., & Ag Ahmed, M. A. (2020). Rethinking the electronic health record through the quadruple aim: Time to align its value with the health system. BMC Medical Informatics and Decision Making, 20(32). https://doi.org/10.1186/s12911-020-1048-9 

Alomari, A., Sheppard‐Law, S., Lewis, J., & Wilson, V. (2020). Effectiveness of clinical nurse’s interventions in reducing medication errors in a pediatric ward. Journal of Clinical Nursing, 29(17-18), 3403–3413. https://doi.org/10.1111/jocn.15374 

Azadegan, A., Srinivasan, R., Blome, C., & Tajeddini, K. (2019). Learning from near-miss events: An organizational learning perspective on supply chain disruption response. International Journal of Production Economics, 216, 215–226. https://doi.org/10.1016/j.ijpe.2019.04.021 

Carver, N., Hipskind, J. E., & Gupta, V. (2019, April 28). Medical errors. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430763/ 

Colquhoun, D. A., Shanks, A. M., Kapeles, S. R., Shah, N., Saager, L., Vaughn, M. T., Buehler, K., Burns, M. L., Tremper, K. K., Freundlich, R. E., Aziz, M., Kheterpal, S., & Mathis, M. R. (2020). Considerations for integration of perioperative electronic health records across institutions for research and quality improvement. Anesthesia & Analgesia, 130(5), 1133–1146. https://doi.org/10.1213/ane.0000000000004489 

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

Devoe, C., Gabbidon, H., Schussler, N., Cortese, L., Caplan, E., Gorman, C., Jethwani, K., Kvedar, J., & Agboola, S. (2019). Use of electronic health records to develop and implement a silent best practice alert notification system for patient recruitment in clinical research: Quality improvement initiative. JMIR Medical Informatics, 7(2), e10020. https://doi.org/10.2196/10020 

Elliott, R. A., Camacho, E., Jankovic, D., Sculpher, M. J., & Faria, R. (2021). Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Quality & Safety, 30(2), 96–105. https://doi.org/10.1136/bmjqs-2019-010206 

Gildon, B., Condren, M., & Hughes, C. (2019). Impact of electronic health record systems on prescribing errors in pediatric clinics. Healthcare, 7(2), 57. https://doi.org/10.3390/healthcare7020057 

González, G. A. C. (2022). Electronic health records: Its effects on the doctor-patient relationship and the role of the computer in the clinical setting. Health and Technology, 12. https://doi.org/10.1007/s12553-021-00634-7 

Kavanagh, A., & Donnelly, J. (2020). A lean approach to improve medication administration safety by reducing distractions and interruptions. Journal of Nursing Care Quality, 35(4), 1. https://doi.org/10.1097/ncq.0000000000000473 

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

Kwon, C.-Y., Lee, B., Kwon, O-Jin., Kim, M.-S., Sim, K.-L., & Choi, Y.-H. (2021). Emotional labor, burnout, medical error, and turnover intention among South Korean nursing staff in a university hospital setting. International Journal of Environmental Research and Public Health, 18(19), 10111. https://doi.org/10.3390/ijerph181910111 

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. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-08818-1 

Melnyk, B. M., Tan, A., Hsieh, A. P., Gawlik, K., Arslanian-Engoren, C., Braun, L. T., Dunbar, S., Dunbar-Jacob, J., Lewis, L. M., Millan, A., Orsolini, L., Robbins, L. B., Russell, C. L., Tucker, S., & Wilbur, J. (2021). Critical care nurses’ physical and mental health, worksite wellness support, and medical errors. American Journal of Critical Care, 30(3), 176–184. https://doi.org/10.4037/ajcc2021301 

Montgomery, A. P., Azuero, A., Baernholdt, M., Loan, L. A., Miltner, R. S., Qu, H., Raju, D., & Patrician, P. A. (2020). Nurse burnout predicts self-reported medication administration errors in acute care hospitals. Journal for Healthcare Quality, 43(1). https://doi.org/10.1097/jhq.0000000000000274 

Nurmeksela, A., Mikkonen, S., Kinnunen, J., & Kvist, T. (2021). Relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: A correlational study. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06288-5 

Rangachari, P., & L. Woods, J. (2020). Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers. International Journal of Environmental Research and Public Health, 17(12), 4267. https://doi.org/10.3390/ijerph17124267 

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

Rodziewicz, T., & Hipskind, J. (2020). Medical error prevention (pp. 1–37). http://www.saludinfantil.org/Postgrado_Pediatria/Pediatria_Integral/papers/Medical%20Error%20Prevention%20-%20StatPearls%20-%20NCBI%20Bookshelf.pdf 

Wu, A. W., Shapiro, J., Harrison, R., Scott, S. D., Connors, C., Kenney, L., & Vanhaecht, K. (2020). The impact of adverse events on clinicians: What’s in a Name? Journal of Patient Safety, 16(1), 1. https://doi.org/10.1097/pts.0000000000000256