Capella 6016 Assessment 1

 Assessment-1: Adverse Event or Near-Miss Analysis

Student Name

Capella University

School of Nursing and Health Sciences, Capella University

NURS-FPX 6016 Assessment 1:

Quality Improvement of Interprofessional Care

Prof. Name:

Date

Adverse Event or Near-Miss Analysis

In the United States, adverse events and near misses are significant concerns that impact patient safety within the healthcare system. Adverse events can be classified as either preventable or unpreventable, depending on the circumstances. Preventable adverse events occur when healthcare providers fail to meet the appropriate standard of care for patients (PSNET, 2019). Sadly, medical errors, including medication errors, rank third among the leading causes of death (Rodziewicz & Hipskind, 2020), with approximately 250,000 medical error-related deaths occurring annually in the US (Anderson & Abrahamson, 2017). This assessment aims to explore adverse events in the healthcare system, their impact on stakeholders, and strategies and technologies that can help reduce such occurrences.

Patient Scenario

Julie Parker, a 65-year-old female with diabetes mellitus, experienced symptoms of heart failure and shortness of breath. She was admitted to Vila Healthcare Hospital, where her initial examination revealed a blood sugar level of 160mg/dl. The doctor ordered her blood sugar to be reassessed every 8 hours, and when the subsequent test showed an increase to 270mg/dl, nurses planned to analyze her prescription through the medication administration database. NURS-FPX 6016 Assessment-1: Adverse Event or Near-Miss AnalysisName.Unfortunately, a series of events led to an adverse outcome. A nurse, who was preparing an insulin syringe for Julie, received an emergency call from another patient and left the room. Later, the nurse administered both insulin and furosemide together, causing severe negative effects, and Julie’s sugar level plummeted to 45mg/dl. Despite the immediate intervention, Julie ultimately passed away. The adverse event was attributed to factors such as excessive workload, multi-tasking, and a culture that allowed interruptions during drug administration (PSNET, 2019).

Implications of the Adverse Event for Stakeholders

The adverse event had far-reaching implications for various stakeholders involved. On the patient and family level, the consequences were devastating, resulting in loss of life and profound grief. Additionally, the family’s trust in healthcare services was significantly damaged. Nursing staff faced criticism for their role in the error, leading to disciplinary actions, such as job loss. Hospital’s higher management and administration also suffered, as their reputation and credibility were tarnished, and financial losses were incurred in the form of compensation payments to the affected family. The incident highlighted the need for a patient safety culture and interprofessional teamwork to prevent such events (Farokhzadian et al., 2018).

Medication Error Prevention Strategies

To prevent future adverse events, healthcare facilities should implement interprofessional education on medication and patient safety. Promoting interprofessional collaboration and effective communication can reduce cognitive pressures on healthcare providers and minimize interruptions during drug administration (Irajpour et al., 2019). The use of technologies such as automated dispensing cabinets (ADC) and the Situation, Background, Assessment, and Recommendation (SBAR) tool can also be beneficial (Müller et al., 2018).

ADC and SBAR Technologies

ADCs, computerized systems that store and dispense medications, can significantly reduce medical errors by providing accurate medication management and reducing manual errors (Jazmyn Lee, 2022). SBAR enhances communication among healthcare providers and helps prevent errors due to poor communication (Ruhomauly et al., 2019).

Other Institutions Implementing Prevention Measures

In the US, institutions like Mayo Clinic and Johns Hopkins Medicine have successfully implemented ADCs and electronic health record systems, respectively, to reduce medical errors (Sparks, 2021) (JohnsHopkinsMedicine, 2022).

Criteria for Evaluating Technologies

Evaluation of these technologies should consider key performance indicators such as patient safety, patient satisfaction, healthcare facility revenue, and workforce competency (Chen et al., 2019). The adoption of evidence-based practices and compliance with preventive guidelines from agencies like AHRQ and CDC are essential to ensuring successful implementation (Research, 2020).

Quality Improvement Initiative to Prevent a Future Adverse Event or Near Miss

In a healthcare setting, one of the core elements is patient safety. It is essential to administer drugs accurately to bring successful healthcare outcomes. In Vila Health, the development of a new strategy for the future prevention of adverse or near-miss events is important.NURS-FPX 6016 Assessment-1: Adverse Event or Near-Miss Analysis. In Vila Health, the incident occurred because of the lack of adverse event reporting protocols. For QI initiatives the use of a model would be the optimal choice to consider for improvements. 

Plan-Do-Study-Act (PDSA)

It is the best model for QI in the healthcare system. The PDSA cycle is highly effective in problem-solving and bringing change in the healthcare sector (Health, 2022). By using the PDSA model, Vila Health can improve quality by collecting feedback from the nursing staff. Nurses can share their problems such as excessive workload, absence of healthcare protocols, and lack of interprofessional collaboration (Health, 2022). 

For future prevention of adverse events, an adverse event reporting system is found as an effective program. Research. (2020) declared that the adverse reporting system by FDA known as (FEARS) is a web-based interactive tool used to report the adverse event in its database. This helps healthcare providers to take knowledge about adverse events and enhance patient safety by improving the lack of healthcare patient safety policies (Research, 2020). FEARS are successful evidence-based practices to enhance healthcare quality because they helped the healthcare community during Covid-19 by providing complete information on adverse events (Research, 2020). 

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

So, the PDSA model can be applied to collect feedback from the Vila Health nursing community to prevent adverse medical errors, and also FEARS dashboard must be introduced to report adverse event occurring in healthcare facilities. 

Conclusion

To sum up, patient safety is a major focus of every high-quality healthcare setting but also a major challenge for modern healthcare institutions. The healthcare setting’s culture, resources, and human resource capabilities are the major factors that must be analyzed to prevent medical errors. Furthermore, drug administration is a highly crucial process that requires proper focus, training, concentration, and strong cognitive capabilities of nursing staff. Healthcare settings must introduce ADC, SBAR, and other drug dispensing protocols to prevent adverse healthcare issues.

References 

Anderson, J., & Abrahamson, K. (2017). Your Health Care May Kill You: Medical Errors. Nih.gov. https://pubmed.ncbi.nlm.nih.gov/28186008/ 

Azyabi, A., Karwowski, W., & Davahli, M. R. (2021). Assessing Patient Safety Culture in Hospital Settings. International Journal of Environmental Research and Public Health, 18(5), 2466. https://doi.org/10.3390/ijerph18052466 

Berdot S, Vilfaillot A, & Bézie Y, et al. (2021). Effectiveness of a “do not interrupt” vest intervention to reduce medication errors during medication administration: A multicenter cluster randomized controlled trial. Ahrq.gov, 20(1). https://psnet.ahrq.gov/issue/effectiveness-do-not-interrupt-vest-intervention-reduce-medication-errors-during-medication 

Berdot, S., Vilfaillot, A., Bezie, Y., Perrin, G., Berge, M., Corny, J., Thi, T. T. P., Depoisson, M., Guihaire, C., Valin, N., Decelle, C., Karras, A., Durieux, P., Lê, L. M. M., & Sabatier, B. (2021). Effectiveness of a “do not interrupt” vest intervention to reduce medication errors during medication administration: A multicenter cluster randomized controlled trial. BMC Nursing, 20(1). https://doi.org/10.1186/s12912-021-00671-7 

Chen, Y., Wu, X., Huang, Z., Lin, W., Li, Y., Yang, J., & Li, J. (2019). Evaluation of a medication error monitoring system to reduce the incidence of medication errors in a clinical setting. Research in Social and Administrative Pharmacy, 15(7), 883–888. https://doi.org/10.1016/j.sapharm.2019.02.006 

Farokhzadian, J., Dehghan Nayeri, N., & Borhani, F. (2018). The long way ahead to achieve an effective patient safety culture: Challenges perceived by nurses. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-3467-1 

Health. (2022, October 3). PDSA: Plan-Do-Study-Act (Rapid Cycle Improvement) – Minnesota Dept. of Health. Health.state.mn.us. https://www.health.state.mn.us/communities/practice/resources/phqitoolbox/pdsa.html#:~:text=More%20Information- 

Irajpour, A., Farzi, S., Saghaei, M., & Ravaghi, H. (2019). Effect of interprofessional education of medication safety program on the medication error of physicians and nurses in the intensive care units. Journal of Education and Health Promotion, 8(196). https://doi.org/10.4103/jehp.jehp_200_19 

Jazmyn Lee. (2022, March 3). Automated Dispensing Cabinets. Swissloghealthcare.com https://www.swisslog-healthcare.com/en-gb/company/blog/drug-dispensing-with-automated-dispensing-cabinet 

Johns Hopkins Medicine Epic. (2022, January 1). Epic Overview. Hopkinsmedicine.org. https://www.hopkinsmedicine.org/epic/ 

Mortaro, A., Pascu, D., Pancheri, S., Mazzi, M., Tardivo, S., Bellamoli, C., Ferrarese, F., Poli, A., Romano, G., & Moretti, F. (2019). Reducing iInterruptions during drug medication preparation and administration: An Improvement Project. International Journal of Health Care Quality Assurance, 32(6). https://doi.org/10.1108/ijhcqa-12-2017-0238 

Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: A systematic review. BMJ Open, 8(8), 1–10. https://doi.org/10.1136/bmjopen-2018-022202 

Patient Safety Network. (2019, September 7). Adverse Events, Near Misses, and Errors. Ahrq.gov. https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors 

Research, C. for D. E. and. (2020). FDA Adverse Event Reporting System (FAERS) Public Dashboard. FDA.gov. https://www.fda.gov/drugs/questions-and-answers-fdas-adverse-event-reporting-system-faers/fda-adverse-event-reporting-system-faers-public-dashboard 

Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical Error Prevention. Nih.gov. https://pubmed.ncbi.nlm.nih.gov/29763131/ 

Ruhomauly, Z., Betts, K., Jayne-Coupe, K., Karanfilian, L., Szekely, M., Relwani, A., McCay, J., & Jaffry, Z. (2019). Improving the quality of handover: implementing SBAR. Future Healthcare Journal, 6(2), 54. https://doi.org/10.7861/futurehosp.6-2s-s54 

Sparks, D. (2021, February 7). Medication errors: Cut your risk with these tips. Newsnetwork.org.  https://newsnetwork.mayoclinic.org/discussion/medication-errors-cut-your-risk-with-these-tips/ 

Tu, H.-N., Shan, T.-H., Wu, Y.-C., Shen, P.-H., Wu, T.-Y., Lin, W.-L., Yang, Y.-H. K., & Cheng, C.-L. (2022). Reducing medication errors by adopting automatic dispensing cabinets in critical care units. Researchsquare. https://doi.org/10.21203/rs.3.rs-2306944/v