Adverse Event or Near Miss Analysis Nursing Medication Error Essay Example

Adverse Event or Near Miss Analysis Nursing Medication Error Essay Example

Near-Miss Analysis

When working in a health facility, people have known or heard of someone who has experienced a near-miss event. A near-miss is an occurrence that could have possessed severe outcomes but did not. In a near-miss, a mistake happened, but the patient did not encounter harm. Any healthcare provider involved in such an episode must adopt suitable changes to decrease the probability of such events reoccurring. When an organization supports its employees, reports regarding adverse or near-miss events will likely reduce. Thus, in these institutions, a sense of partnership, constructive criticism, and trust must exist between staff and administration. This will assist in learning, assessing, and tackling errors so enhancement metrics can happen for patient safety. The near-miss occurrence in this paper involved a patient admitted with chronic obstructive pulmonary (COPD).

Evaluation of Missed Steps and Protocol

A comparatively new staff nurse was assigned to someone with severe alcohol withdrawal. Notably, this withdrawal was not the admitting diagnosis for this male in his sixties. The man was aggressive and challenging to handle. He caused much anxiety and stress to the new staff nurse, who needed additional co-workers to control the patient. Notably, the man was admitted for COPD, and within forty-eight hours, he went into alcohol withdrawal. After deliberations with the wife, a decision to give the patient whiskey nightly was reached. The doctor was apprised and instructions to instigate Clinical Institute Withdrawal Assessment. Also, to control the patient’s conduct, Ativan was prescribed. The staff nurse gave him 2 mg IV two times during the shift. The upset spouse, who had never seen the husband in such a situation, aggravated the circumstances.

Further, the medication was kept safe in a drug room freezer, and for the second dose, the staff nurse removed the medication from its storage and administered the dose that she contemplated she had earlier. In the facility, it was not unexpected for many nurses to extract the medicines from the freezer and sign the dosage later by recording it in the client’s file. The staff nurse administered 1 mg IV, not 2 mg, for this second dosage. This could have led to prolonged usage of Ativan by the male patient because the withdrawal symptoms would have continued. However, the physician corrected this during the next dosage and stabilized the patient before polypharmacy occurred.

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Moreover, the protocol divergence linked to this occurrence comprised the nurse presuming the client’s dose based on the past dosage and removing the medicine from the freezer. Further, it was associated with the administration of drugs without scanning the amount. Examining the client’s armband and scanning the barcode on the medication would have alerted the staff nurse on the accurate dosage to administer adverse event or near miss analysis nursing medication error essay example.

Even though the patient-nurse ratio was optimal during the night shift when the event happened, the disruptions caused by the patient and trying to calm the spouse and patient affected the staff nurse’s attention and memory. During drug administration, nurses are required to be alert to avoid mistakes that would hurt the patient Adverse Event or Near Miss Analysis Nursing Medication Error Essay Example.

Evaluation of Implications of the Negative Occurrence on all Stakeholders

Many stakeholders, like the patient, spouse, nurse, physicians, and pharmacists, are impacted if such an occurrence happens (Latimer et al., 2017). In this situation, the patient was the first stakeholder to be affected. Instead of stabilizing after the second dosage, the aggravation continued, and after the nurse realized the mistake, the physician corrected the error. The patient had to stay on the medication longer because of the missed dose. The anxiety and aggravation continued into the morning. However, there was no elevated harm to the patient. The nurse was also affected, and even though she was not dismissed, she had to undergo mandatory training and education on medication errors (Rodziewicz & Hipskind, 2020). She realized the mistake after scanning the medication and realized the dose differed from the first. After the incident, the nurse was under immense psychological pressure, so she had to see a counselor. The physician also suffered from shame because they believed that was a preventable mistake even though it did not adversely affect the patient. Another stakeholder is the spouse, who suffered mental anguish because she did not see any changes in the husband even after the second dose. Notably, the patient and spouse would have to incur additional costs for the extra dose. Lastly, the matter was settled amicably because the wife did not want to press any charges against the hospital. This means the hospital was not affected much.

Assessment of Qualitative Enhancement Technologies

After the event, there was a need to adopt and implement a medication management and control strategy. It is a QI technique that utilizes performance assessment information to help the healthcare facility identify future grounds and defects for task turnarounds throughout care provision. This lets healthcare professionals know the proper medication regimen and syringe for dispensing. For instance, if the patient’s bedside display were linked to an automated dispensing cabinet (ADC), the staff nurse would have easily remembered the previous dosage because of the markers on the dashboard (Zheng et al., 2021). The drug name, infusion time, and dosage information would have been found on the dashboard. Thus, this drug management strategy can be viewed as the appropriate technology-based QI enhancement strategy that would have averted this near-miss occurrence.

Pertinent Measures of Quality Enhancement for the Institution

Using pertinent metrics and key performance indicators (KPIs) while executing quality improvement (QI) plans is supported by the importance of client satisfaction and safety in achieving the mission, vision, and corporate operation objectives. Information on age-linked doses, alternative drugs, and acute challenges are key performance indicators that endorse tech-based investments at the facility. For pharmacists and nurses to adhere to the accurate dispensation of drugs to the right person, the KPIs are vital. Remarkably, the Institute of Health Improvement has designed metrics for averting medication mistakes in the clinical framework. Such an institution asserts that these metrics help prevent unfortunate occurrences that lead to morbidity or mortality while under therapy.

QI Initiative to Prevent a Future Adverse Event or Near-miss

Medication mistakes can be a severe challenge that subjects patients to preventable threats. These errors are viewed as a nursing issue, but every healthcare professional plays a vital function in prevention. To avert future near-miss, a continuous quality improvement principle-like system approach can be utilized to boost medical professionals’ motivation and excellent conduct. The system approach exposes the origin of systemic challenges that trigger workarounds of safety standards and adversely impact patient safety and then utilizes the data to recognize excellent solutions to concerns. On the contrary, this method will be suitable for transforming environmental and institutional attitudes that champion workarounds and user uncertainty toward tech innovations because decision-making bestows drug dispatch mistakes in each healthcare institution. This systems approach will assist nurses in adhering to set processes for dispensing medication and other practice norms for giving enhanced care. Therefore, using a systems approach in the future can help execute programs that will help achieve the magnet hospital level adverse event or near miss analysis nursing medication error essay example. Magnet hospitals possess high degrees of patient and staff satisfaction, portraying they value nurses and acknowledge the significance of offering exceptional client experience.

Conclusion

All healthcare professionals strive to offer high-quality services, which is challenging for many institutions. Medication errors can lead to acute physical harm and mortality. These preventable errors can also cause serious psychological, financial, and emotional stress to the organization and healthcare professionals. Underdosing can lead to polypharmacy since extra medications are required to accomplish preferred outcomes. In this case, the patient received an underdose; even though it did not have adverse effects, it was an error that should be avoided in the future. Further, protocol deviations and missed steps by the nurse were examined. Also, stakeholders and how they were influenced by this underdosing were examined. Even though near-miss occurrences are not harmful to patients and are highly unlikely to cause mortality, nurses and other healthcare professionals must strive to avoid them. Adopting mechanisms that can help nurses to avoid these errors can help healthcare facilities achieve patient and staff satisfaction.

References

Latimer, S., Hewitt, J., Stanbrough, R., & McAndrew, R. (2017). Reducing medication errors: Teaching strategies that increase nursing students’ awareness of medication errors and their prevention. 
Nurse Education Today
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52
, 7-9.

Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. 
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing
.

Zheng, W. Y., Lichtner, V., Van Dort, B. A., & Baysari, M. T. (2021). The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review. 
Research in Social and Administrative Pharmacy
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17
(5), 832-841.

 

Adverse Event or Near Miss Analysis Nursing Medication Error Essay Example

Prepare an analysis (5-7 pages) of an adverse event or a near miss from your professional nursing experience and outline a QI initiative that would address it.

Near miss–( medication error: Adminstered less medication than prescribed in error)

Introduction

Health care organizations strive to create a culture of safety. Despite technological advances, quality care initiatives, oversight, ongoing education and training, legislation, and regulations, medical errors continue to be made. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. Many errors are attributable to ineffective interprofessional communication.

Overview

The goal of this assessment is to allow you to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a QI initiative to prevent future incidents. It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself in as a health care professional.

Health care organizations strive for a culture of safety. Yet, despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation, and regulations, medical errors continue to occur. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation.

Historically, medical errors were reported and analyzed in hindsight. Today, QI initiatives attempt to be proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by new technologies and reporting metrics, adverse events and near misses can provide insight into potential ways to improve care delivery and ensure patient safety.

For clarification, the National Quality Forum (n.d.) defines the following:

Adverse event: An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.

Near miss: An event or a situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention.

Instructions

Prepare a comprehensive analysis of an adverse event or a near miss from your professional nursing experience that you or a peer experienced. Provide an analysis of the impact of the same type of adverse event or near miss in other facilities. How was it managed, who was involved, and how was it resolved? Be sure to:

Analyze the implications of the adverse event or near miss for all stakeholders.

Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.

Evaluate QI actions or technologies related to the event that are required to reduce risk and increase patient safety.

Evaluate how other institutions integrated solutions to prevent these types of events.

Incorporate relevant metrics of the adverse event or near miss to support need for improvement.

Outline a QI initiative to prevent a future adverse event or near miss.

Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Be sure your analysis addresses all of the above points. You may also want to read the Adverse Event or Near Miss Analysis Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Adverse Event or Near Miss Analysis [DOCX] document for additional clarification about things to consider when creating your assessment.

Additional Requirements

Your assessment should also meet the following requirements:

Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page or References section.

Number of references: Cite a minimum of three sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master’s Program (MSN) Library Guide for guidance adverse event or near miss analysis nursing medication error essay example

APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.

Analyze the implications of an adverse event or a near miss for all stakeholders.

Analyze the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis.

Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.

Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.

Evaluate and identify quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.

Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.

Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Reference

National Quality Forum. (n.d.). NQF patient safety terms and definitions. http://www.qualityforum.org/Topics/Safety_Definitions.aspx