Adverse Event or Near-Miss Analysis Assignment

Implications of an Adverse Event

The occurrence of an adverse event within an organization can have a range of implications for various stakeholders, who typically include patients, healthcare providers, the organization itself, and the broader healthcare system. For patients, the most immediate implication of an adverse event is the potential for harm, which can range from temporary discomfort to long-term disability or even death. Patients may also experience financial burdens due to additional treatments and potential loss of income (Liukka et al., 2020). Healthcare providers involved in an adverse event may face emotional impacts such as guilt, anxiety, and a loss of confidence, which can contribute to burnout. Liukka et al. (2020) further identify the risk of legal consequences, which can affect personal and professional reputation. An adverse event can serve as a learning opportunity, prompting providers to reflect on their practices and engage in professional development to prevent future occurrences.

From an organizational standpoint, adverse events can lead to financial costs associated with litigation, settlements, and increased insurance premiums. There may also be a loss of reputation, which can impact patient volume and revenue. Consequently, Liukka et al. (2020) contend that organizations may need to invest in training and system improvements to prevent recurrence. Adverse events can be used by organizations to proactively improve patient safety and quality of care without the added burden of managing actual harm to patients. For the broader healthcare system, adverse events can indicate systemic issues that require attention. They can lead to policy changes, increased regulatory oversight, and modifications to clinical guidelines. Adverse events contribute to the body of knowledge that informs best practices and prevention strategies (Liukka et al., 2020).

The analysis assumes that all stakeholders are invested in the outcomes of healthcare delivery. It presumes that adverse events and near misses have emotional, financial, and professional repercussions for healthcare providers. It considers that patients prioritize safety and that these events impact their trust. The analysis is based on the notion that organizations will respond to incidents with policy changes aimed at improvement. It also assumes that the healthcare system at large is capable of and committed to learning from these occurrences to enhance overall patient care and safety practices.

Adverse Event

In a bustling hospital, amid the whirlwind of medical care, a pivotal moment unfolded involving a nursing student on a clinical rotation. The incident centered on a medication error during the administration of a patient’s treatment. It began with the admission of a new patient diagnosed with pneumonia. His medical history was intricate, and a complex regimen of medications was prescribed to aid in his recovery. These medications ranged from antibiotics to pain management and anticoagulants, all crucial to his treatment plan. The responsibility of administering these medications fell on the shoulders of a diligent nursing student guided by a seasoned registered nurse (RN). The morning medication round commenced at 9:00 AM, a routine part of hospital care.

However, amidst the hustle and bustle of the busy ward, a crucial step was missed. The nursing student inadvertently picked up a medication vial that closely resembled the correct one but was not the prescribed anticoagulant. Without double-checking the label against the medication order, the medication was administered to the patient. It was only moments later that the student realized the grave error. Swiftly, the mistake was reported to the supervising RN, and immediate action was taken to address the situation. The root cause of this medication error, upon reflection, stemmed from the failure to double-check the medication vial label against the medication order before administration—an essential verification step. A breakdown in communication between the nursing student and the RN further compounded the issue. Additionally, the hospital’s medication storage system lacked safeguards to prevent the proximity of similar-looking medications, contributing to the mix-up.

Quality Improvement Actions and Technologies

To enhance patient safety and reduce the risk of medication errors like the one described in the incident involving a nursing student, several critical quality improvement actions and technologies should be considered. These measures aim to create a safer healthcare environment and prevent such errors from occurring in the future. Firstly, the implementation of a Barcode Medication Administration (BCMA) system is paramount. BCMA systems use barcodes to match patient information, medication orders, and medication administration, significantly reducing the likelihood of errors. Nurses and nursing students would be required to scan both the patient’s wristband and the medication label before administering any medication (Wu et al., 2020). Any discrepancies would trigger alerts, ensuring the correct medication is administered to the right patient. Additionally, revising the hospital’s medication storage system is crucial. Medications with similar appearances should be stored separately or distinctly labeled to minimize the risk of confusion (Gyber et al., 2022). Clear and standardized labeling practices should be adopted throughout the organization to ensure accurate identification.

Robust double-check protocols for medication administration should be implemented, involving a second healthcare provider independently verifying the medication against the medication order before administration. This additional step is a crucial safety net to catch any discrepancies or errors. Effective communication training for healthcare providers, including nursing students, should be emphasized, ensuring that crucial information is relayed accurately and promptly within the healthcare team (Gyber et al., 2022). Establishing a robust error reporting system and a feedback loop to analyze reported incidents and near misses, along with simulation training, can further enhance medication safety. Continuous Quality Improvement (CQI) teams should be formed to review incidents, near misses, and quality data regularly, identifying trends and areas for improvement. Integrating medication orders and administration records into the electronic health record (EHR) system, improving medication reconciliation processes, and involving patients and their families in the medication administration process are essential steps to enhance overall patient safety (Gyber et al., 2022).

To assess the effectiveness of the proposed actions and technologies for improving patient safety, several key criteria should be considered. Firstly, their ability to reduce medication errors and adverse events should be evaluated, measuring the actual impact on patient safety. Additionally, the level of compliance among healthcare providers with the new protocols and technologies should be monitored. Patient feedback and satisfaction regarding medication safety and their involvement in the process can provide valuable insights. Cost-effectiveness should be assessed, weighing potential savings from avoided errors and litigation costs against implementation expenses. The impact of training on healthcare providers’ skills and confidence, as well as the seamless integration of technologies into existing workflows, should also be analyzed. Finally, the organization’s capacity for continuous improvement based on feedback and incident analysis is a crucial factor in evaluating the overall success of these measures.

Quality Improvement Initiative

The “Medication Safety Enhancement Initiative” is designed to prevent future adverse events related to medication errors and elevate overall patient safety within the healthcare organization. The initiative unfolds in a well-structured process comprising several essential phases:

Phase 1: Assessment and Planning

In this initial phase, the incident analysis takes center stage. A thorough investigation into the recent medication error incident is conducted, focusing on identifying root causes and analyzing contributing factors. Stakeholder engagement becomes pivotal, with healthcare providers, administrators, and patients actively participating in discussions to gain diverse perspectives on medication safety (Laatikainen et al., 2022). Concurrently, data collection efforts are initiated, with a focus on gathering information regarding medication error rates, near misses, and patient feedback linked to medication administration.

Phase 2: Development of Action Plan

Building upon the insights gathered in the assessment phase, a comprehensive action plan is formulated. Key elements of this plan include the implementation of a Barcode Medication Administration (BCMA) system to ensure accurate medication administration by matching patient information, medication orders, and administration records (Laatikainen et al., 2022). Additionally, enhancements are made to the medication storage system, preventing look-alike medications from being stored near each other and introducing standardized labeling practices. Clear double-check protocols for medication administration are established, involving a second healthcare provider in verification. To foster effective communication and teamwork, mandatory communication training is conducted for all healthcare providers.

Phase 3: Implementation and Evaluation

With the action plan in place, the organization proceeds with implementation. The BCMA system is introduced, and careful attention is given to seamless integration into the EHR system. Simulation training sessions are launched to provide nursing students and healthcare providers with opportunities to practice medication administration in a controlled environment. Continuous monitoring becomes a priority, with ongoing assessment of medication error rates, compliance with new protocols, and solicitation of patient feedback to gauge the effectiveness of the initiative (Gyber et al., 2022).

Phase 4: Feedback and Improvement

A robust feedback mechanism is established, allowing healthcare providers and patients to report errors, near misses, and suggestions for improvement. A dedicated Continuous Quality Improvement team convenes regularly to review incidents, near misses, and quality data, identifying trends and areas for further enhancement (Vikan et al., 2023).

Phase 5: Ongoing Education and Training

Sustainability is emphasized in this phase, with ongoing education and training programs implemented to ensure that healthcare providers remain up-to-date on best practices in medication safety. Patient engagement continues to be a priority, with patients actively involved in their medication safety and care plans, and their input and feedback are actively sought (Vikan et al., 2023).

Phase 6: Reporting and Communication

Transparency in reporting medication errors and near misses is a cornerstone of the initiative. Lessons learned from incidents are shared openly with the broader healthcare community. Regular communication with stakeholders, including patients, is maintained to update them on the progress and outcomes of the initiative, fostering trust and garnering support (Laatikainen et al., 2022).

Conclusion

Adverse events within healthcare organizations have significant implications for patients, healthcare providers, the organization itself, and the broader healthcare system. These implications encompass emotional, financial, and professional consequences. To address and prevent such events, quality improvement actions and technologies, including Barcode Medication Administration (BCMA) systems, revised medication storage practices, communication training, and robust error reporting mechanisms, play a crucial role. The “Medication Safety Enhancement Initiative” offers a structured approach to enhance medication safety, involving thorough assessment, action planning, implementation, ongoing evaluation, feedback mechanisms, continuous education, and transparent communication. By prioritizing patient safety and continuous improvement, healthcare organizations can mitigate risks and ensure a higher standard of care.

References

Gyberg, A., Henoch, I., Lepp, M., & Ulin, K. (2022). Framing healthcare professionals in written adverse events: A discourse analysis. Nursing Inquiry, 29(3), e12461. https://doi.org/10.1111/nin.12461

Laatikainen, O., Sneck, S., & Turpeinen, M. (2022). Medication-related adverse events in health care—what have we learned? A narrative overview of the current knowledge. European Journal of Clinical Pharmacology, 11(3), 1-12. https://doi.org/10.1007/s00228-021-03213-x

Liukka, M., Steven, A., Vizcaya Moreno, M. F., Sara-Aho, A. M., Khakurel, J., Pearson, P., & Tella, S. (2020). Action after adverse events in healthcare: An integrative literature review. International Journal of Environmental Research and Public Health, 17(13), 4717. https://doi.org/10.3390/ijerph17134717

Vikan, M., Haugen, A. S., Bjørnnes, A. K., Valeberg, B. T., Deilkås, E. C. T., & Danielsen, S. O. (2023). The association between patient safety culture and adverse events–a scoping review. BMC Health Services Research, 23(1), 1-27. https://doi.org/10.1186/s12913-023-09332-8

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), 65–72. https://doi.org/10.1097/PTS.0000000000000256

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The goal of this assessment is to allow you to focus on a specific event in a healthcare 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 healthcare professional.

Healthcare 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 the need for improvement.

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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] Download 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.

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