Adverse Event or Near Miss Analysis

Adverse Event or Near Miss Analysis


Re-envisioning the widespread commitment and the diagnostic process is critical to illuminate the diagnostic error’s blind spots and improve healthcare diagnosis. Diagnostic errors are increasingly growing and are becoming a serious issue in the healthcare unit, and there seems to be not much that can be done to bring a change.

However, despite the increasing cases of diagnostic errors, the hospitals must make a few recommendations to ensure they improve patient outcomes and address other challenges. This paper will focus on a misdiagnosis case in my workplace and describe stakeholders’ implications to provide functional recommendations to resolve the issue.

I will share my colleague’s experience with a mid-aged woman, Mrs. Johnson, who had a rectal bleeding problem. In her case, the doctor conducted a limited sigmoidoscopy test, which came out negative. The bleeding, on the other hand, did not stop even after she underwent numerous treatment methods.

After about two years, the patient’s condition got worse, and she had to return to the facility. As per her assessment, she had lost at least 10 kgs within that time. After further evaluation of her condition, the doctor diagnosed her with colon cancer, which was at a relatively advanced stage.

The doctor indicated in his assessment that based on the previous medical record, the issue could have been identified earlier when there were still chances for cure. However, the event was ruled adverse due to the medical negligence she encountered previously.

Analysis of the Missed Steps That Lead To the Adverse Events

A bright bleeding per rectum is a common clinical issue that adults of all ages often experience. However, when it comes to young adults, the issue is not well reported, causing an assumption that it is not common for a particular age group (Segev et al., 2018). In this regard, doctors need to perform colonoscopy within the first time of diagnosis to evaluate rectal bleeding considering that it could present multiple risks of colorectal neoplasms.

According to Jodal et al. (2019), at least 10% of patients with rectal bleeding have been diagnosed with colorectal cancer. It would have also been helpful for the doctor to consider other options in his testing, such as adenomatous polyps.

Another reason this was considered an adverse event is that the doctor would have conducted further tests when the patient expressed that the bleeding was still there rather than expecting that the issue would disappear magically. The doctor failed to test for neoplastic lesions, which are located in the distal colon of almost all patients with rectal bleeding.

There is also a possibility of patients having hemorrhoids and adenocarcinoma in the transverse colon. The doctor should have also considered tumors as a reason for the bleeding, hence conducting a colonoscopy to rule out the issue (Jodal et al., 2019). The distribution of polyps is very similar to that of colorectal cancer patients. Therefore, the doctors’ job was to ensure they ran a comprehensive test and considered a few possibilities.

Rigid sigmoidoscopy is a diagnostic procedure used to rule out colorectal pathology (Segev et al., 2018). It is frequently performed in outpatient clinics and requires minimal intestinal preparation. Flexible sigmoidoscopy, on the other hand, is a more advanced test with a higher diagnostic value and less patient discomfort than a rigid sigmoidoscopy.

As for the case of Mrs. Johnson, a middle-aged patient, it would have been convenient to get her screened for colorectal cancer. The patient and the doctor should have also had an agreement on the appropriate tests between sigmoidoscopy and colonoscopy that will be effective and bring the necessary result.

Data provided by Segev et al. (2018) indicate that at least 90% of the patients in the clinic are flexible to take sigmoidoscopy, which is clinically significant. On the other hand, those that may opt for a colonoscopy are also guaranteed that the test is effective and will bring convenient results for those in need of colorectal cancer screening and are above the age of 50 years (Cheluvappa & Selvendran, 2020).

It would also be convenient to investigate whether any visible cultural differences between the patient and the physician could have impacted the course of treatment. The difference in cultural understanding directly influences the treatment approach for various patients.

Implications of Medical Negligence of Stakeholders

Patients have an ethical responsibility towards their health and the cost regulations. However, the regulations cannot effectively be implemented or strictly force people into living a healthy lifestyle. By embracing a healthy lifestyle, it is guaranteed that the cost of healthcare will be significantly reduced.

On the other hand, it is critical for people with medical insurance to have the best insurance cover possible to make them comfortable, especially with the current expansion of innovation. The doctors, on the other hand, are expected to ensure they provide the expected services to their target clients.

However, it is also convenient to understand that the best medical services should not necessarily be expensive. Therefore, the doctors and the patients are expected to work together and ensure they reach a sensible health decision. As for the case of Mrs. Johnson, it would have been best for her to visit the doctor as soon as she noticed the issue had not been resolved rather than waiting all that long.

Additionally, considering that she was not satisfied with the conclusion of the previous doctor, it would have been best for her to seek a second and third opinion. The short-term consequences of the near-miss incident were low customer satisfaction, which resulted in a reduction in the number of patients served by the hospital.

The problem could result in significant losses in the long run. Customers would cease coming to the hospital, and there is a considerable risk of legal action, which would result in financial losses. The problem will be remedied by immediately treating the patient and finding measures to reimburse her for the initial misdiagnosis (Sapoelete et al., 2021). For example, the hospital could agree to pay for all of her future treatments, whether they occur at the hospital or elsewhere.

Interprofessional Team

Patients depend on the interprofessional team intervention to receive reliable care and monitor the rise in healthcare costs. However, on the part of the interprofessional team, they often have a limited time to attend to specific patients and review their specific medical charts due to the increasing number of patients and the high cost of healthcare. Such issues have contributed to the increased cases of medical negligence (Cheluvappa & Selvendran, 2020).

Health professionals are committed to doing everything possible for the patient’s benefit. Doctors are expected to make decisions on their own, with little regard for the interests of their patients. Even while they act freely, the interprofessional team should respect patients’ rights while deciding on the best care for them.


A community’s role is to guarantee that all patients receive the greatest treatment options possible. The community owes it to health practitioners to push them to offer the appropriate degree of treatment for all patients, regardless of insurance or cost, while also addressing their needs (Curtis et al., 2021). The community’s responsibility is to ensure that all patients, affluent and poor, receive equal treatment while seeking medical care.

Diagnosis and Technologies

When it comes to the diagnosis and treatment, it is critical to understand the patient’s information in detail. Therefore, the physician has to ensure they use the best and most relevant technology that will help in the diagnosing and treatment process to guarantee improved patient outcomes. With the best technology, physicians can lower the cost of treatment and reduce the time spent on specific patients (Carayon & Hoonakker, 2019).

In the case of Mrs. Johnson, there is a higher possibility that her condition was not discovered earlier due to a lack of proper inclusion of technology in the diagnosis process. In the healthcare setting, service delivery largely depends on collecting, storing, and analyzing patient information. Therefore, when it is not done effectively, the service delivery will be impaired, affecting the patient outcome.

To achieve better results, using technology such as Health Information System (HIS) guarantees better clinical data collection and storage, improving patient care outcomes (Sapoelete et al., 2021). The technology helps physicians capture specific patient information and minimize the risks of duplicating patient information, preventing misdiagnosis. HIS is also easy to use and super friendly to the users. Regarding maintenance, the technology is relatively straightforward and does not attract huge costs.

Metrics for Adverse Event Support

Cases of medical errors are increasingly growing, affecting people from across all age groups. Each year, nearly 230000 people die as victims of medical negligence (Anderson & Abrahamson, 2018). I have witnessed at least seven deaths resulting from our staff malpractice during my practice. Studies further show that at least one in every 70 cancer cases results from misdiagnosis within the appropriate time when there are chances of getting treatment.

Still, due to late discovery, the problem escalates, making it difficult to resolve. The late discovery of the disease makes it escalate into a severe stage where the treatment process will be ineffective and costly for the patient (Carayon & Hoonakker, 2019). Therefore, caregivers must conduct proper and detailed diagnoses to minimize or eliminate misdiagnosis. It is also critical to evaluate the depth of the mistake and identify positive and effective ways to correct the issue.


Such problems can be prevented if health devices and technology are properly used. In the healthcare industry, the introduction of computers and other devices has greatly increased the amount of patient data stored at one time. Furthermore, the continuous updating of devices provides accurate prescriptions and medicine even when symptoms change (Curtis et al., 2021). With the use of technology, all patient information will be accessible, making it simple for caregivers to locate in an emergency.

Consequently, Mrs. Johnson’s condition would have been handled differently if the initial physician who attended to her case had used technology during the diagnosis procedure. If one physician cannot make a proper diagnosis, technology assures that another can. Team collaboration is also necessary to achieve evidence-based quality improvement through sharing essential patient information for enhanced decision-making.


As per the case of Mrs. Johnson, medical negligence made it difficult for her to access professional assistance when she needed it the most. Doctors and patients have a role in handling the issue of medical negligence. Therefore, it is critical to formulate a functional relationship and guarantee that the issues leading to errors are resolved. The health institutions also have a role to play in ensuring improved patient outcomes.


Anderson, J. G., & Abrahamson, K. (2018, January). Your Health Care May Kill You: Medical Errors. In ITCH (pp. 13-17). doi: 10.1007/s10729-009-9111-1.

Carayon, P., & Hoonakker, P. (2019). Human factors and usability for health information technology: old and new challenges. Yearbook of Medical Informatics28(01), 071-077 DOI: 10.1055/s-0039-1677907.

Cheluvappa, R., & Selvendran, S. (2020). Medical negligence-Key cases and application of legislation. Annals of Medicine and Surgery57, 205-211.

Curtis, N. J., Dennison, G., Brown, C. S., Hewett, P. J., Hanna, G. B., Stevenson, A. R., & Francis, N. K. (2021). Clinical evaluation of intraoperative near misses in laparoscopic rectal cancer surgery. Annals of Surgery273(4), 778-784. doi: 10.1097/SLA.0000000000003452

Jodal, H. C., Helsingen, L. M., Anderson, J. C., Lytvyn, L., Vandvik, P. O., & Emilsson, L. (2019). Colorectal cancer screening with fecal testing, sigmoidoscopy or colonoscopy: a systematic review and network meta-analysis. BMJ Open9(10), e032773.

Sapoelete, R., Muhadar, M., Yudianto, O., & Budiarsih, B. (2021). The Concept of Penal Mediation for the Crime of Medical Negligence in Realizing Legal Protection for Medical Personnel and Patients or Their Families. International Journal of Multicultural and Multireligious Understanding8(2), 147-151. DOI:

Segev, L., Kalady, M. F., & Church, J. M. (2018). Left-sided dominance of early-onset colorectal cancers: a rationale for screening flexible sigmoidoscopy in the young. Diseases of the Colon & Rectum61(8), 897-902. doi: 10.1097/DCR.0000000000001062

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