Student Name
Capella University
NURS-FPX 6016 Quality Improvement of Interprofessional Care
Prof. Name
Date
Adverse Event or Near-Miss
Healthcare organizations work hard to create a safe environment for patients. However, even with technology, rules, and laws, medication errors still happen. A study conducted over the period of four years electronically reported 632 near-missed events, and it happened with nurses who had one to nine years of experience (Yoon & Sohng, 2021). This assessment looks at a near miss that occurred in a healthcare setting. At night, due to overcrowding. It will analyze the incident, examine the root cause, and explore effective quality improvement actions; this assessment will propose a plan to prevent future errors and improve patient safety.
Implications for Stakeholders
As a fellow nurse working the night shift in a busy hospital, I witnessed a near miss that highlighted the importance of thorough protocols at Stanford Health Care. One evening, a nurse named Rachel was responsible for administering medication to several patients. One patient named Mr. Johnson was scheduled to receive a dose of insulin due to diabetes. While preparing the medication, the nurse was interrupted by a call from another patient’s room. In haste, the nurse administered the insulin to Mrs. Thompson, who was in an adjacent bed and did not have diabetes. Fortunately, Rachel was about to inject the insulin, but glanced at the patient’s wristband and realized the mistake. The nurse immediately stopped and double-checked the medication order and patient identification, making it a near miss event.
Implications for Stakeholders
This near miss at Stanford Health Care was a close call that could have led to severe consequences if the wrong patient had received the insulin. The short and long-term effects of such near miss events on patients, families, Interprofessional teams, and facilities are paramount. Mrs. Thompson was at risk of potential hypoglycemia; immediate medical interventions were needed, and it would have increased anxiety and distrust in the healthcare system (Tsegaye et al., 2020). Mr. Thompson could have also faced issues due to delays in receiving necessary insulin, potential hyperglycemia, and concerns about the care’s reliability.
Rachel personally was distressed about losing trust from colleagues and supervisors along with the potential consequences of adverse events due to wrong patient medication administration. She felt self-doubt but with reporting and ensuring that interruption was avoided, she was able to learn the importance of focus and open communication about her duties regarding safe medication administration. The Interprofessional team would feel stress and guilt and face disciplinary action in the long term, impacting practice license. The facility could face legal issues and negative publicity (Vaismoradi et al., 2021).
NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis
This event underscored the need for strict adherence at Stanford Health Care to the five rights of medication administration: the right patient, drug, dose, route, and time. I realized that the interdisciplinary team has some responsibilities to ensure no such near-miss events occur and lead to adverse events. For instance, nurses are meant to verify patient identity before administering medication and follow the five rights of the administration process (Hanson & Haddad, 2023). The doctors at the facility must ensure clear and accurate medication orders and collaborate with nurses to confirm treatment plans.
Pharmacists are responsible for double-checking orders and dosages while educating staff about medication safety (Westbrook et al., 2020). Moreover, the administration should create and enforce policies to minimize interruptions during medication preparation and ensure training on patient safety protocols. Upon reflection and reporting the incident, the interdisciplinary team should conduct a Root Cause Analysis (RCA) to understand how this near miss occurred (Westbrook et al., 2020).. I realized through this incident that no interruption zone around the medication preparation area and reinforcement of the importance of double-checking patient identification before medication administration is essential.
Assumptions
The analysis is based on certain assumptions; most prominently, the interdisciplinary team is collectively responsible for medication administration. Ineffective communication among healthcare providers and between patients and care providers contributes to medical errors. This implies the assumption that the facility must ensure no interruption zones and train healthcare staff, especially nurses, to follow the five-rights double-checking method while communicating with patients. This analysis also assumes that patient education is paramount for maintaining trust and preventing near misses related to medication (Westbrook et al., 2020).
Root Cause Analysis of Medication Administration Error
As mandated by The Joint Commission, RCA was implemented to identify underlying factors that led to the medication administration near-miss incident. RCA highlighted that the event at Stanford Health Care resulted from a medication administration process deviation rather than the patient’s underlying condition. The disposition of medication error resulting in the near-miss event highlights the major concerns. The near miss occurred due to human error during medication preparation and administration, highlighting system failure rather than a medical condition-related issue that jeopardizes trust and reputation in the facility (Singh et al., 2023). In the incident, RCA demonstrates the sequence of events, such as the nurse being interrupted while preparing medication for Mr. Johnson and almost administering insulin intended for Mr. Johnson to Mrs. Thompson. Then, the nurse realizes the mistake before administering the insulin to the wrong patient.
The missed steps leading to near miss event are the failure to maintain focus and verify patient identity during medication preparation. The lack of a designated no-interruption zone or clear protocol for medication preparation at Stanford Health Care leads to distraction and potential errors. The interruption during medication preparation diverted the nurse’s attention, causing them to overlook verifying patient identity before administering the insulin. Clear communication channels between nurses and other healthcare team members, such as doctors, could have prevented the event. For example, if Rachel had communicated the interruption or confirmed the medication order with a colleague, the error might have been caught before reaching the patient. The adverse event was highly preventable. Implementation of no-interruption zones, stricter medication preparation protocols, and enhanced communication among Interprofessional teams could significantly reduce the risk of similar near misses in the future (Mutair et al., 2021).
Knowledge Gaps and Areas of Uncertainty
The analysis could benefit from further information on the frequency and types of interruptions nurses face during medication preparation at Stanford Health Care. How well current protocols are followed for verifying patient identity and medication orders needs to be clarified. So, further information is needed to assess the impact of current training or education programs on staff adherence to safety protocols, preventing near miss or adverse events. Moreover, comparing the effectiveness of no-interruption zones and other safety measures across healthcare settings could inform best practices. Addressing these uncertainties through data collection and comparative analysis can improve the accuracy of the RCA and subsequent Quality Improvement (QI) initiatives.
Evaluation of Quality Improvement Actions and Technologies
Several strategies can be considered to evaluate and identify QI actions or technologies at Stanford Health Care in the near-miss event of administering insulin to the wrong patient. For instance, designating specific areas where medication preparation occurs without interruptions can reduce distractions and enhance focus, minimizing the risk of medication errors (Sloane et al., 2023). Implementing Barcode Medication Administration (BCMA) or electronic verification tools, its strict integration that requires nurses to monitor the patient’s wristband and medication level before administration can significantly reduce medication errors (Mulac, 2021). Using secure messaging platforms or Electronic Health Records (EHRs) can allow real-time communication of critical patient information, facilitating the quick verification of medication orders and patient identities (Ocaña et al., 2023). It will facilitate in preventing near miss events with use of technology and effective communication.
Evaluation Criteria
Few evaluation criteria exist for actions or technologies that ensure safe medication administration at Stanford Health Care. By evaluating these criteria comprehensively, healthcare facilities can identify the most suitable and effective QI actions or technologies to reduce adverse event risk and enhance patient safety in medication engagement (Whitfield et al., 2021).
- Assessing the effectiveness of implemented actions such as no-interruption zones or technologies such as Barcode Medication Administration (BCMA) reduces the occurrence of near misses related to medication errors (Mulac, 2021).
- Usability is another criterion that ensures that barcode and no interruption zones are implemented into the existing workflow without causing disruptions or hindering efficiency.
- Ensure that electronic devices like EHRs and BCMA provide accurate results, such as correct patient identification and medication administration.
- A study states that adverse events can cost 5.4 million dollars annually due to injuries or death incidents (Ciapponi et al., 2021). Cost-effectiveness analysis can be utilized to compare potential savings from preventing adverse events and improving patient safety.
- Gathering feedback from healthcare professionals regarding their experience of implemented action can be utilized to improve areas and optimize effectiveness.
Data from the Stanford Health Care’s dashboard, including administration logs, error reports, and compliance rates, can provide trends in medication errors or near misses, giving insights into the effectiveness of QI measures. Further, patient satisfaction and readmission rates can reflect concerns related to medication safety. Research outside institutions can provide insights into best practices against benchmarks for medication safety, error prevention strategies, and the effectiveness of technology solutions. Internal data analysis with external benchmarks will help align strategy with industry standards (Xie et al., 2022).
Quality Improvement Initiative
The matter was addressed with specific actions at Stanford Health Care where the near-miss event occurred. Firstly, the incident is reported and documented per organizational policy to report any near-miss case. The near miss was reported to relevant authorities to understand the potential adverse event due to a medication administration error. Post-reporting RCA identified the event’s root cause, highlighting interruption and poor communication issues, which resulted in a near-miss event (Whitfield et al., 2021). Moreover, it highlighted the improper usage of BCMA technology and adherence to five-right protocols for medication administration, for which the following actions were taken as QI initiatives.
Through training, staff was encouraged to use the BCMA technology correctly, and its integration into existing workflow was implemented. A study states that BCMA technology reduces medication errors by adherence to rights and improves patient identification (Mulac, 2021). Next, no-interruption zones were established during critical tasks and overcrowding scenarios for medication preparation and administration. The staff members were educated regarding the importance of minimizing distractions and interruptions during medication administration tasks.
Research states that these zones improve focus and accuracy in medication administration, reducing adverse events and preventing near miss incidents (Sloane et al., 2023). Lastly, clear communication protocols for verifying medication orders and patient identities, emphasizing collaboration among all stakeholders, including patients. Encouraging open communication to speak about critical tasks during rush hour and interact with patients for double-identification reduces the chances of medication errors or adverse events (Westbrook et al., 2020). The QI initatives usage can prevent future adverse events or near misses related to medication errors. However, regular evaluations, feedback loops, and continuous training ensure sustainability and ongoing improvement in patient safety practices (Xie et al., 2022).
Conclusion
In conclusion, the near-miss incident of administering insulin to the wrong patient underscored critical issues in medication safety, including interruptions, poor communication, and system failures. Through a comprehensive quality improvement initiative, including implementing BCMA technology, establishment of no-interruption zones, and clear communication protocols, the healthcare facility has taken significant steps to prevent future adverse events or near misses related to medication errors. These actions, backed by evidence-based practices and ongoing evaluation, demonstrate a commitment to enhancing patient safety and reducing risks in medication administration.
References
Ciapponi, A., Nievas, S. E. F., Seijo, M., Rodríguez, M. B., Vietto, V., García-Perdomo, H. A., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Garcia-Elorrio, E. (2021). Reducing medication errors for adults in hospital settings. Cochrane Database of Systematic Reviews, 2021(11). https://doi.org/10.1002/14651858.cd009985.pub2
Hanson, A., & Haddad, L. M. (2023). Nursing rights of medication administration. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560654/
Mulac, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223
NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis
Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improve reporting systems. Medicines, 8(9). https://doi.org/10.3390/medicines8090046
Ocaña, M. J. R., Morales, C. T., Pichardo, J. D. R., & Hernández, M. A. (2023). Barriers and facilitators of communication in the medication reconciliation process during hospital discharge: Primary healthcare professionals’ perspectives. Healthcare, 11(10), 1495. https://doi.org/10.3390/healthcare11101495
Singh, G., Patel, R. H., & Boster, J. (2023). Root cause analysis and medical error prevention. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570638/
Sloane, J. F., Donkin, C., Newell, B. R., Singh, H., & Meyer, A. N. D. (2023). Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda. Journal of General Internal Medicine, 38(6). https://doi.org/10.1007/s11606-022-08019-w
NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis
Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, 13(13), 1621–1632. https://doi.org/10.2147/ijgm.s289452
Vaismoradi, M., Jordan, S., Logan, P. A., Amaniyan, S., & Glarcher, M. (2021). A systematic review of the legal considerations surrounding medicines management. Medicine, 57(1), 65. https://doi.org/10.3390/medicina57010065
Westbrook, J. I., Li, L., Raban, M. Z., Woods, A., Koyama, A. K., Baysari, M. T., Day, R. O., McCullagh, C., Prgomet, M., Mumford, V., Dalla-Pozza, L., Gazarian, M., Gates, P. J., Lichtner, V., Barclay, P., Gardo, A., Wiggins, M., & White, L. (2020). Associations between double-checking and medication administration errors: A direct observational study of pediatric inpatients. BMJ Quality & Safety, 30(4), 320–330. https://doi.org/10.1136/bmjqs-2020-011473
Whitfield, K., Coombes, I., Denaro, C., & Donovan, P. (2021). Medication utilisation program, quality improvement and research pharmacist—implementation strategies and preliminary findings. Pharmacy, 9(4), 182. https://doi.org/10.3390/pharmacy9040182
NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis
Xie, C. X., Chen, Q., Hincapié, C. A., Hofstetter, L., Maher, C. G., & Machado, G. C. (2022). Effectiveness of clinical dashboards as audit and feedback or clinical decision support tools on medication use and test ordering: A systematic review of randomized controlled trials. Journal of the American Medical Informatics Association, 29(10). https://doi.org/10.1093/jamia/ocac094
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