Comprehensive Analysis on a Near Miss or Adverse Nursing Event

Comprehensive Analysis on a Near Miss or Adverse Nursing Event

Healthcare institutions employ the best evidence-based practices, and thus practices are constantly changing. Quality improvement projects in institutions help improve practice and promote patient safety. However, errors due to various causes occur. These errors may be sentinel events, medical emergencies, mild adverse effects, or near misses.

The severity of these errors depends on the type of error and the impact on patients’ and healthcare providers’ health and safety. When they occur, they probe healthcare institutions to develop strategies to ensure such an event does not occur in the future. This paper analyzes an adverse nursing event (medication) error and proposes quality improvement projects to prevent the event’s occurrence in the future.

A 20-year lady was wheeled to the emergency department and diagnosed with hypokalemia. She was on diuretics due to her hypertensive condition. The doctor prescribed a 300mEq potassium intravenous infusion to run for five hours. The emergency department nurse, a newly deployed nurse from the medical ward, overlooked the flow rate and administered the drug bypassing the IV drug administration pump. She ran the infusion in one hour, exposing the patient to various hyperkalemia risks. The patient developed fatal arrhythmias and died shortly afterward.

Analysis of Missed Steps and Protocol deviations Related to Adverse

The emergency department records the highest rate of medication errors in the hospitals, and this department’s hasty nature, panic, and confusion contribute significantly to medication errors. Root cause analysis of errors and the development of quality improvement projects are thus integral in this department. Several missed steps may cause the sentinel event.

The doctor prescribed a higher drug flow rate (60mEq) than the allowed flow rates (20-40mEq), and the nurse did not realize the mistake (Vanholder et al., 2018). The nurse also failed to ensure all the rights of medication, further aggravating the situation. She ignored the right frequency. She also bypassed the IV drug infusion pump and administered the drug with a usual drop stand which is challenging to regulate the IV flow rate. She did not follow the institution’s protocol of administering IV potassium infusions with a medication companion using a drug infusion pump.

Contrary to the standard practice, the patient was not adequately monitored. Patients under potassium IV infusing require constant monitoring such as ECG, checking serum potassium levels, and vitals, especially blood pressure and pulse rates (Hunter & Bailey, 2018). A doctor prescribes ECG monitoring, and he did not specify it in this case. ECG monitoring would have effectively managed this patient, detected the arrhythmias, and allowed for patient management.

The results of the events show several deficits in the nurse’s knowledge. She lacks an understanding of potassium toxicity. She also lacks an understanding of the institution’s protocols on managing potassium infusion. Understanding these institutional protocols and management algorithms and those set by regulatory agencies such as the Agency for Healthcare Quality and Research is essential in helping avoid the occurrence of such events in the future. The incident was preventable if these regulatory stipulations were followed.

Effects of the Sentinel Event on the Various Stakeholder

Medication errors are undesirable and lead to various effects in other healthcare institutions. The first stakeholder to get affected is the patient. The patient did not have control over the event, and she suffered most of the consequences. The event, in this case, caused loss of patient life. The patient’s family suffered grief, psychological trauma, and healthcare costs associated with losing a loved one. In addition, they fear healthcare institutions which may affect how they perceive healthcare institutions, healthcare professionals, and their health-seeking behavior (Mannion & Daves, 2018).

The interprofessional team will suffer consequences resulting from the event. The interprofessional team is the perpetrator of the event. The interprofessional team did not collaborate in care such as follow-up and monitoring, and thus the errors were not discovered early enough to prevent the irreversible damage. An interprofessional team failed by allowing a newly deployed nurse to manage a patient without supervision.

Healthcare professionals suffer psychological trauma witnessing or getting involved in preventable errors that lead to sentinel events (Manias, 2018). The guilt affects the individuals’ performance. In addition, healthcare institutions may carry out disciplinary actions such as suspension and job losses. Patients or their families sometimes decide to sue the hospital for damages caused by these preventable errors. These lawsuits are often hefty, exposing them to high healthcare costs and sometimes imprisonment.

The organization is tasked with ensuring ethical responsibility by ensuring staff understands the organizational and regulatory requirements. The healthcare institution suffers a soiled reputation from such events. The institution has failed in orienting new nurses to the respective roles and the regulations affecting their practice in the various hospital departments (Manias et al., 2018).

Care delivery is different from department to department, and staff orientation is thus a prerequisite. The institution suffers from decreased patient influx from fear of recurrence of such an event. If the patient’s family decides to sue the hospital, the hospital may incur high costs from these lawsuits and also a further soiled reputation when these cases reach media houses.

All members have a role in the interprofessional to create a safety culture. The healthcare providers were expected to collaborate to ensure the care provided was conversant with practice (Manias, 2018). Patient follow-up is not an only-nurses role, and the doctor should have followed on the patient’s progress.

In addition, the nurse leader should have oriented these nurses to nurses’ roles in the emergency department. Orientation and socialization of nurses in new departments improve interprofessional consultation, improving quality care delivery and patent safety. Continuing education programs to enhance the nurses’ knowledge of handling patients in the emergency would have helped create a safety culture at the workplace (Mannion & Davies, 2018). The leader would have also assigned a nurse to supervise her and only allowed her to work independently after learning all emergency department protocols.

After the incident, the healthcare institution developed and emphasized ensuring the presence of a medication assistant before drug administration. Healthcare consultation spreads accountability to many healthcare providers and ensures errors are not overlooked. The policy increased the healthcare providers’ responsibility and prevented another sentinel event. Nurses discovered that they administer drugs without a companion are subject to disciplinary actions in the healthcare institution.

Evaluation of Quality Improvement Technologies

The Institute of Medicine (IOM) reports that medication errors cause mortality and morbidity, with 0.724% outpatient deaths and 0.125% inpatient deaths, with significant morbidities such as paralysis, organ failure, and mental health issues resulting from medication errors (Leape, 2021). Healthcare records are the basis for healthcare quality improvement projects.

Quality records are the cornerstone for healthcare decision-making. Healthcare data analysis enables healthcare providers and leaders to determine areas for improvement and plan interventions to improve healthcare delivery and patient safety. Thus, quality healthcare data collection technologies are integral to quality improvement projects.

Computerized provider order entry (CPOE) and clinical decision support systems (CDSS) systems are the leading healthcare technology promoting patient safety. CPOE helps healthcare providers avoid legibility errors and missing links, while the CDSS is the most significant intelligence system that provides diagnosis and treatment-related information to a healthcare professional (Angela & Adisasmito, 2019). These systems have significantly helped reduce medication errors by pointing out incorrect dosages and frequencies and wrong medications for specific diagnoses. In the sentinel event, the CDSS system would have alerted the infusion rates of IV potassium infusion, preventing the perpetrated clinical error.

According to Mortimer et al. (2018), quality improvement projects are driven by specific objectives and goals used to measure improvement projects’ success. These goals and objectives can be prepared using computers and provide consistent and reliable data to evaluate the success of quality improvement projects.

Computed data, visual dashboards are integral in determining the success of healthcare institutions. Healthcare dashboards are prepared by hospitals and comply with the local, state, and federal agencies’ stipulations regarding managing various conditions (Pestana, Pereira, & Moro, 202). Institutions prepare dashboards as internal goals to measure internal achievement and progress towards promoting patient safety and quality care delivery. These dashboards also measure an institution’s success relative to the external regulations.

Dashboards help improve patient safety and improve healthcare services quality. Dashboards are applied in all hospital departments, and they give real-time information to clinicians on relevant department-specific categories. Coupled with CDSS systems, they guide professionals’ clinical decisions to ensure safe and quality healthcare delivery (Kunjan, Doebbeling, & Toscos, 2019).

They also help clinicians stay focused on organizational goals, and they have been successful in promoting change interventions and enhancing their success. These dashboards follow a general design, but hospitals can alter these designs to meet their needs. The hospital, St. Claire Medical Center (SCMC), can develop specific dashboards to steer organizational goals achievement.

Relevant metrics for Quality Improvement

Dashboard metrics have service-specific key performance indicators. The key performance indicators for quality improvement projects on medication administration errors are based on patient-clinician interactions. They are basically process (clinician-centered) and outcome (patient-centered) key performance indicators (Topos, 2019). The data from electronic health records will provide formidable information on following set protocols and achieving desired patient health outcomes.

The Agency for Healthcare Research and Quality and the Institute for healthcare improvement is responsible for healthcare improvement projects. The AHRG controls quality improvement in various areas such as disease-specific management (heart disease and diabetes management measures), patient safety (patient falls and healthcare patient information safety), and disease prevention measures (children immunizations) (AHRQ, n.d.). Through the Network for Patient Safety Databases (NPSD), AHRQ reports metrics specific to the emergency department, including blood and blood products errors, device or medical/surgical supply errors, and medication and other substance errors (AHQR 2021).

The medication error-specific metrics focus on the type, cause, and severity of the medication errors. Some important key performance indicators by the AHRQ and NPSD include heart failure mortality and death rates in the low-mortality-diagnosis-related groups (AHRQ, 2021). Healthcare institutions can develop key performance indicators aligned with these regulations to ensure adherence and improve quality care delivery and patient safety.

The healthcare institution relevant metrics would include a) LASA related medication rates, b) medication errors death rates, c) death rates from uncomplicated diseases, d) average waiting time for patients to be seen, e) blood and blood product-related adverse effects in the ED, and f) medication near-miss error reports (Leape, 2021). The hospital can integrate healthcare technologies to improve patient safety. The CPOE, CDSS, and dashboard metrics integration provide a formidable tool for evaluating healthcare decisions, patient safety, and quality improvement.

Dashboards improve healthcare delivery and promote patient safety. They act as evaluation tools and a source of motivation to healthcare providers and healthcare institutions. According to Kunjan et al. (2019), dashboards support healthcare professionals in rational decision-making. According to Isazan, Ojo, and Sullivan (2020), dashboards provide formidable professional evaluation tools to help professionals measure their practice and perform personal improvement towards achieving organizational goals and objectives.

In another study, dashboards increase staff morale and are a source of motivation to healthcare providers. According to Pestana, Pereira, and Moro (2020), dashboards increase professional accountability and responsibility, resulting in high-quality and safe patient care.

Quality Improvement Initiative for SCMC

Current best practices to prevent medication errors include using the IV drug pump. Healthcare technology controls drugs and avoids dosage, drug, and frequency errors. Other initiatives include bedside handing over patients using the ISBAR tool and the use of medication companions (Wolf, 2018). Handing-over patients at the bedside familiarize nurses with the patients under their care and prevent errors after forgetting or confusing patients and their medications. Another strategy implemented is medication companions. Medication companions help prevent errors such as information misinterpretation, reading errors, and detecting errors perpetrated by other healthcare providers.

Quality improved models include the Donobedian (structure, process, and outcome), PDSA (Plan, Do, Study, and Act) cycle, and the Six Sigma Models (Define, Measure, Analyze, Implement, and Control) (Goldman et al., 2021). These Six Sigma and PDSA cycle models outline related processes integral in ensuring the best evidence-based practices for the quality improvement project.

The six sigma model is formidable in determining errors and their causes and planning evidence-based strategies to address these issues. The PDSA cycle shortfall is its inability to determine causes and address cause-specific errors. The Baldrige criteria significant shortfall is inapplicability in clinical practice settings as it is more inclined to classroom settings (Menezes et al., 2018). LEAN thinking and Six Sigma models are somewhat similar but have variations in their explanation of the causes of errors; processes versus conduct errors (AHRQ, 2020).

Quality improvement projects focus on techniques to improve care quality and patient safety, and hence, the Sigma model is the best in creating the outline for the improvement project (AHRQ, 2020). The model improves efficiency by providing a systematic approach that produces well-researched, analyzed, and evaluated data.

Quality improvement integrated initiatives involving multidisciplinary teams are the best to enhance healthcare improvements. An integrated CDSS, CPOE, dashboards program, and The Six Sigma model quality improvement strategy will significantly improve healthcare settings. The four components have had marked healthcare settings’ success, and their integration will lead to a superimposed increase in healthcare efficiency and reduced medication errors in all departments.


Healthcare QI projects are often tedious and involve a lot of data work. Data collection from the patient-healthcare provider interaction to an analysis of the data involves different healthcare technologies. Healthcare leaders must be willing to invest in the data analysis process to develop an effective evidence-based intervention to improve healthcare settings and ensure high-quality care and patient safety. Thus, healthcare leaders must ensure comprehensive data collection and analysis for quality decision-making. As seen above, integration of the Six Sigma model, Clinical provider order entry, and clinical decision support systems provide a quality improvement project outline.


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