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

Near-miss incidents and adverse events in healthcare serve as critical indicators of system weaknesses and offer valuable insights for enhancing care delivery. The analysis focuses on a near-miss incident involving a medication administration error. A nurse identified a mismatch between the extra dose of acetaminophen administration given to the patient. The incident underlines the need for standardized protocols, clear communication, and meticulous verification to support patient safety (Mulac et al., 2020). This evaluation will explore the event’s consequences, the order of actions, and the root cause analysis. It will outline a quality improvement (QI) strategy to mitigate future risks. Addressing this challenge aims to foster a safety culture and minimize medication administration errors.

Implications for Stakeholders

During a busy shift at Saint Mary Hospital’s pediatric unit, Nurse Emily gave James, a 7-year-old child, an extra dose of acetaminophen, recently diagnosed with a mild ear infection and fever. This error occurred during the handoff between me and the night shift nurse, who failed to double-check the Medication Administration Record (MAR) in the Electronic Health Record (EHR).

Moreover, critical information regarding the child receiving a prior dose during my shift was not communicated. Three hours after the second dose, James became mildly drowsy. Fortunately, he was closely monitored and treated without any severe adverse effects. However, this incident highlighted the need for improved communication, medication reconciliation, and verification procedures. The root cause was a lapse in the handoff process and inadequate cross-checking of critical medication details.

Implications

The incident can have both immediate and lasting repercussions for various stakeholders. It includes the patient and their family, the interprofessional team, the organization and the broader community. In the short term, James and his family faced distress and a loss of confidence in the facility’s procedures, particularly if any severe adverse effects, such as liver damage or jaundice, occurred. Such complications could lead to serious conditions like acute liver or kidney failure, long-term organ damage, or even death (Naser & Al-shehri, 2023). However, no physical harm resulted from the incident.

It underscored existing system weaknesses, diminishing patient trust in future care. The long-term effects could manifest as persistent anxiety over potential errors. It impacts the healthcare team comprising nurses, doctors, and pharmacists, prompting self-reflection and heightened concern. In the immediate outcome, the investigation and double verification processes for medication administration added to the workload. At the same time, longer-term consequences include retraining on safety protocols or issuing warnings to prevent future medication administration errors (Naser & Al-shehri, 2023).

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

The night shift nurse faced accountability concerns due to the failure to verify the MAR before administering the extra dose, necessitating retraining on medication safety protocols. The day shift nurse, despite correctly documenting the medication, experienced heightened vigilance in future handoffs, emphasizing the need for clearer communication during shift transitions.Incidents such as near-misses have significant consequences for the hospital. It includes reputational damage that can reduce community confidence. It will experience financial consequences for conducting inquiries, staff training, and reviewing procedures.

To minimize the risks, the hospital must focus on building a safety culture and integrating advanced technologies, such as Barcode Medication Administration (BCMA), clinical decision support systems (CDSS), and advanced communication methods. These approaches ensure that these near misses are not progressive to serious events. This would make the community aware of the safety standards of the hospital and the quality of care being offered. The institution must maintain transparency and take responsibility to regain people’s trust. The interprofessional team is responsible for ensuring medication safety through accurate documentation, thorough communication, and adherence to verification protocols.

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

The night shift nurse should have reviewed the MAR and confirmed the last administered dose before giving another, while the day nurse needed to emphasize this during the handoff. Pharmacists play a crucial role in reviewing prescriptions for potential errors or duplications. Key measures that should have been taken include utilizing Barcode Medication Administration (BCMA) for real-time verification, implementing clinical decision support systems (CDSS) to trigger alerts for duplicate dosing, and reinforcing structured handoff protocols to enhance communication (He et al., 2022). The incident impacted stakeholders by increasing vigilance in medication administration, prompting policy reviews, and emphasizing the need for retraining. Nurses became more meticulous in cross-checking medication records, while the hospital reinforced safety protocols and transparency to maintain trust and prevent future errors.

The interprofessional team promotes patient safety through effective communication and adherence to standardized verification protocols. In James’s case of an extra acetaminophen dose, automatic alerts for duplications and improved handoff processes enhanced care delivery. First, the night shift nurse should communicate the recent medication history and pharmacists must review prescriptions for accuracy and potential interactions to safeguard safety. Double-checking medication labels at every step, using BCMA to cross-verify patient data and medication details and incorporating CDSS EHR alerts are essential measures (Stolic et al., 2022).

Assumptions

This analysis presumes that the staff involved in the near-miss were trained in established medication administration protocols, but human error played a role in the incident. It assumes that Saint Mary Hospital had executed safety measures, though these were inadequate to prevent the near-miss from happening. Moreover, it is assumed that the nurse emphasized transparency and clear communication throughout the incident’s resolution. It fosters an environment where the lessons learned could be applied to refine safety protocols and enhance future practice.

Root Cause Analysis of Medication Administration Error

The root cause analysis (RCA) aims to recognize the underlying factors by examining the sequence of events and focusing on preventing future occurrences (Miller, 2021). Initially, during a hectic shift at Saint Mary Hospital’s pediatric unit, Nurse Emily inadvertently administered an extra dose of acetaminophen to James, who was recently diagnosed with a mild ear infection and fever. The error occurred during the handoff between the night shift nurse and me, who neglected to review the MAR in the EHR thoroughly. Furthermore, vital information about James receiving a prior dose earlier in my shift was not communicated.

Fortunately, he was closely observed and treated without experiencing any severe adverse outcomes. This incident underscored the critical need for enhanced communication, medication reconciliation, and verification processes. The primary cause was a breakdown in the handoff procedure and insufficient cross-checking of essential medication details. The potential risk of liver or kidney damage was prevented, not due to any issues with James’s health condition due to staff mismanagement.

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

The primary mistake in this case was during the shift handoff, where critical medication details were not communicated or confirmed. This led to the nurse giving an extra dose of acetaminophen because the patient’s medication history was not verified. This brought out a weakness in the multi-step verification process (Ahn et al., 2021). The RCA of the case indicated technologies like medication dispensing cabinets, CPOE, and barcoding are available at the facility. However, staff didn’t use those technologies adequately cause of limited knowledge about technology utilization. The RCA of the case indicated a lack of adequate training and communication during the shift handover, where some key information relating to medications was not provided, and there was a conflict between the nurses.

A more extensive review should have led to this mistake being avoided. Standardized protocols of handing over should be set, communication enhanced, and patients’ medication needs to be validated through barcode scanning systems. Improved communication during shift changes will mean that all drugs are reviewed adequately before administration. Technologies such as BCMA and CDSS can help by ensuring accurate medication verification. It alerts for inconsistencies and automatically identifies errors to help healthcare providers prevent mistakes (Stolic et al., 2022).

Knowledge Gaps and Areas of Uncertainty

The analysis of this incident exposed several knowledge gaps and areas requiring further clarification. Assessing nurses’ adherence to the multi-step medication verification process is essential. It focuses on the effectiveness of staff training and the consistency with which protocols are followed. While manual double-checking was effective in this case. Exploring technological solutions like BCMA could help minimize human error. Moreover, we must evaluate the communication dynamics during handovers, particularly using standardized tools like checklists to ensure clarity of responsibilities. It is important to investigate how the demands and stress of shift work impact adherence to procedures and attention to detail. These factors can influence staff compliance and the level of care provided during medication administration.

Evaluation of Quality Improvement Actions and Technologies

It is necessary to have QI programs in place along with the use of technology to minimize risks and patient safety. The technologies for preventing medication administration errors include BCMA, CDSS with EHR alerts and effective communication tools. It minimizes human error in shift transition (He et al., 2022). Systems that carry out automatic medication checks are essential in accurately administering medications. If those technologies are not implemented yet, this is a lost chance to enhance safety. Any available technology should be appropriately integrated into medication administration in a healthcare facility where it is likely to be highly needed. Success levels in many other institutions indicate that more than one verification step is applied, such as checking EHR alerts at all stages and regular auditing to ensure consistency with labeling and verification procedures.

Monitoring critical metrics like medication error rates, discrepancies and safety compliance is vital for recognizing patterns and analytic areas that need improvement. Tracking incidents related to medication administration error rates, patient outcomes and staff adherence to established protocols enables healthcare organizations to recognize weaknesses and minimize the risk of adverse events. Research supports integrating technologies like BCMA and EHR alerts and highlights the necessity of multi-layered communication verification processes (He et al., 2022). By comparing internal data with external standards, organizations can identify areas of vulnerability and adopt targeted solutions. If the internal error rate exceeds the national average, focused interventions can be introduced to enhance patient safety and reduce errors.

Criteria to Evaluate Actions or Technologies

Success can be measured through various criteria to evaluate the success of the actions or the technologies. Another important factor would be how efficiently errors are reduced. The important point would be strict compliance with the protocol at all steps of medication administration, such as proper verification of the labels on the medication and adequate utilization of the barcode scanning systems (Pruitt et al., 2023). The important aspect is determining how well these actions and technologies are incorporated into the current workflows because delays or frustration among staff can create further issues.

Patient outcomes are another important measure to assess the effectiveness of interventions that reduce near-misses or adverse events due to medication administration errors. The rate of near-misses or adverse events is a very important measure of the success of the changes. Finally, seeking staff feedback will be important in identifying any resistance to new technologies or protocols and opportunities for improvement in real-world practice settings (Wilson et al., 2022).

Quality Improvement (QI) Initiative

One of the important aspects of QI is its ability to avoid future medication mistakes at Saint Mary Hospital. In this case, Nurse Emily administered extra doses of acetaminophen through an error during the handover between the night nurse and me, who failed to check the details of the medications being given to the patient. The patient was under close care and given treatment with very minimal effects. However, the incident highlighted needing better communication, medication reconciliation, and verification procedures. The fundamental cause was failure in the handover process and lack of cross-checking crucial medication details.

Several elements of the QI program have been demonstrated to work toward reducing medication errors at the point of administration. According to a study, EHR-integrated BCMA and CDSS will reduce medication mistakes with a higher magnitude. It stated that BCMA and EHR-integrated CDSS reduce medication error odds (Isaacs et al., 2020). The analysis showed that when the patient was scanned using the barcode, they got the correct drug at the proper time. Multi-stage verification must involve checking a patient’s identity, drug dose, and history during dispensing up to the final administration stage.

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

Studies show that this can prevent errors and better safety results. Further education and training on standardization of medication administration protocols must not end for the eradication of human errors. Evidence indicates that the routine training of nursing staff will ensure adherence to safety protocols, creating a safety culture (Isaacs et al., 2020). Technologies like EHR-integrated BCMA and CDSS are currently available at the facility, but their complete implementation and staff training are processes that take time and resources (Ahn et al., 2021). 

The PDSA model provides a framework for piloting and refining these technological interventions within the facility. Still, it is important to note that the PDSA cycle is just one of several change models a healthcare organization might use to create a structure for change in a proposed QI initiative. It is not itself the QI initiative. The PDSA cycle focuses on testing, adapting, and integrating the technologies. It ensures they align with the broader QI strategy. The emphasis is not on the immediate availability of these technologies but on how to efficiently implement them over time. It ensures that they contribute to the long-term success of the QI initiative. Adopting and integrating these technologies require infrastructure assessment, training, and system updates, which are either in progress or planned for the future.

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

The PDSA (Plan, Do, Study, Act) cycle was used for Saint Mary Hospital’s QI initiative to prevent future adverse events or near misses. The first phase is the planning stage. Integrating technology would prove useful since automated EHR alerts will help verify medication administration in real-time, reducing the scope of human error. Standardized communication tools, such as checklists and structured handoff protocols between nurses, will improve clarity and consistency (Ahn et al., 2021). Ongoing staff training on drug safety, proper labeling, and handling medication administration challenges will be necessary to ensure best practices. Simulation exercises can be used to assess the staff’s responses to critical situations, improving their preparedness (Isaacs et al., 2020).

With this plan, physicians, nurses, and pharmacists can all align their efforts and identify problems before they arise. In the “Do” phase, the pediatric unit must be audited regularly to uncover process gaps. These audits must be followed up with feedback sessions to remind everyone of the significance of safety protocols. In the “Study” phase, audit, checklists, and staff feedback results must be analyzed and reviewed for effectiveness. Finally, under the “Act” phase, adjustments should be made based on the findings, including refining protocols and taking the successful medication administration processes to the other hospital units, such as the surgical ward.

Conclusion

The near miss-incident of the accidental acetaminophen dose points out huge communication, medication reconciliation and verification gaps at all stages of the healthcare delivery process. QI initiatives such as improved handover practices, BCMA, CDSS, and continuously training staff can pay off handsomely in preventing future such errors. The PDSA cycle helps structure the process of assessing, refining, and improving medication administration practices to ensure patient safety, accountability, and transparency. All these efforts would help Saint Mary Hospital reduce the risks, rebuild trust with the patients and their families, and improve the quality of care.

References

Ahn, J., Jang, H., & Son, Y. (2021). Critical care nurses’ communication challenges during handovers: A systematic review and qualitative meta‐synthesis. Journal of Nursing Management, 29(4). 5-32 https://doi.org/10.1111/jonm.13207

He, M., Huang, Q., Lu, H., Gu, Y., Hu, Y., & Zhang, X. (2022). Call for decision support for high-alert medication administration among pediatric nurses: Findings from a large, multicenter, cross-sectional survey in China. Frontiers in Pharmacology, 13. e2-e19 https://doi.org/10.3389/fphar.2022.860438

Isaacs, A. N., Ch’ng, K., Delhiwale, N., Taylor, K., Kent, B., & Raymond, A. (2020). Hospital medication errors: A cross sectional study. International Journal for Quality in Health Care, 33(1). mzaa136 https://doi.org/10.1093/intqhc/mzaa136

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

Miller, K. (2021). Comparing the effects of traditional education and root-cause analysis on nursing students’ attitudes about safety culture and knowledge of safe medication administration practices. Nurse Educator, 47(3). 139-144 https://doi.org/10.1097/nne.0000000000001126

Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2020). Severe and fatal medication errors in hospitals: Findings from the Norwegian incident reporting system. European Journal of Hospital Pharmacy, 28(1). e56–e61. https://doi.org/10.1136/ejhpharm-2020-002298

Naser, A. Y., & Al-shehri, H. (2023). Paediatric hospitalisation related to medications administration errors of non-opioid analgesics, antipyretics and antirheumatics in England and Wales: A longitudinal ecological study. BMJ Open, 13(11), e080503. https://doi.org/10.1136/bmjopen-2023-080503

Pruitt, Z. M., Kazi, S., Weir, C., Taft, T., Busog, D.-N., Ratwani, R., & Hettinger, A. Z. (2023). A systematic review of quantitative methods for evaluating electronic medication administration record and bar-coded medication administration usability. Applied Clinical Informatics, 14(01), 185–198. https://doi.org/10.1055/s-0043-1761435

Stolic, S., Ng, L., & Sheridan, G. (2022). Electronic medication administration records and nursing administration of medications: An integrative review. Collegian, 30(1), 163–189. https://doi.org/10.1016/j.colegn.2022.06.005

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

Wilson, C., Howell, A.-M., Janes, G., & Benn, J. (2022). The role of feedback in emergency ambulance services: A qualitative interview study. BMC Health Services Research, 22(1). 296 https://doi.org/10.1186/s12913-022-07676-1