NURS FP6016 SimmonsC Assessment 1 Adverse Event or Near Miss Analysis
Adverse Events or Near Miss Analysis
Adverse events in healthcare institutions result in multiple ramifications, including injuries, deaths, disabilities, prolonged hospitalization, and increased care costs. According to Rodziewicz et al. (2022), adverse events are types of injuries that primarily occur due to errors in medical or surgical treatment rather than the underlying medical condition of the patient. These events can be preventable when they emanate from errors and failure to adhere to the clinical guidelines and protocols.
Also, they can be sentinel events that are unanticipated by healthcare professionals. Examples of adverse events include medication errors, patient falls, and wrong-site surgery. While these incidents compromise the tenets of patient safety and care quality, this paper elaborates on a near miss, the potential implications of adverse events on healthcare stakeholders, and evidence-based practices to enhance safety by preventing these events.
Analyzing an Adverse Events or a Near Miss
A near miss that I experienced involved healthcare professionals in the surgical unit. An interdisciplinary team consisting of surgeons, nurses, and assistant nurses was preparing for a coronary artery bypass graft (CABG) operation for a 56-year-old male patient grappling with coronary heart disease. During the preparation, one of the anesthesiologists ordered sodium chloride as a reconstruction agent. However, the nurse provided a vial of succinylcholine instead of sodium chloride. Luckily, the anesthesiologist identified the mistake before administering any neuromuscular blocking agent.
Later, they established that the patient had other underlying conditions such as a history of malignant hyperthermia, and a severe reaction to certain drugs used for anesthesia. Supposing the anesthesiologist did not identify the imminent errors, administering a vial of succinylcholine to a patient with a history of malignant hyperthermia would result in multiple consequences, including massive histamine release associated with hemodynamic instability (Cook & Simons, 2020). In turn, this could lead to allergic reactions and the subsequent threat to patient safety.
Missed Step and Protocol Deviation Related to the Near Miss
The near-miss events resulted from medical management rather than from the patient’s underlying conditions. In this sense, flawed medical management processes, including proper drug packaging, labeling, and nomenclature contributed to the event. For instance, the event signified the underlying intrinsic and extrinsic factors that facilitate medication errors. From a dimension of intrinsic factors, it seems that the nurse failed to distinguish between a vial of succinylcholine and sodium chloride due to their similar appearance.
According to Nkurunziza et al. (2019), some errors are consistent with healthcare professionals’ practices and techniques. In essence, it is valid to argue that the nurse did not apply the merited criteria for selecting drugs due to experience issues, unfamiliarity with clinical guidelines, and time pressure. On the other hand, organizational factors played a significant role in facilitating the event. For example, a lack of an automated dispensing cabinet, improper drug labeling, packaging, and nomenclature contributed massively to the mistake in selecting the correct drug. As a result, it is essential to establish and implement evidence-based interventions to intercept intrinsic and extrinsic risk factors for medication errors.
The Extent to Which the Event Was Preventable
Although adverse events and near misses can result in multiple consequences, they are preventable by undressing the potential risk factors for these events. Rodziewicz et al. (2022) recommend failure mode effect analysis, root cause analysis (RCA), and effective reporting systems as potential approaches for preventing adverse events. However, it is essential to note that these strategies have varying degrees of success in preventing adverse and sentinel events due to the diversities in contextual factors.
For example, it was possible to prevent a near-miss in the surgical unit through proper packaging, labeling, and differentiation of drugs with look-alike appearances. The hospital could have considered installing an automated dispensing cabinet and educating nurses on appropriate strategies to distinguish medications using descriptions rather than appearance. Therefore, the near-miss event provided opportunities for organizational learning and improvement of medication management approaches.
The Impact of the Same Type of Adverse Events or Near Miss in Other Facilities
Although an anesthesiologist prevented the inadvertent use of succinylcholine neuromuscular blocking agent instead of sodium chloride, the subsequent effects of unintended substitution of neuromuscular blocking drugs are detrimental to the patient if proper medical responses are insufficient. According to Lundstrøm et al. (2018), errors when using neuromuscular blocking agents (NMBA) can lead to adverse side effects, including anaphylaxis, cardiovascular effects related to histamine release, bronchospasm, and prolonged paralysis. If timely medical interventions are lacking, these side effects can result in patient death and prolonged hospitalization, alongside legal and professional issues such as lawsuits and licensure revocation by regulatory authorities.
Analyzing the Implications of the Adverse Event or Near Miss for All Stakeholders
Stakeholders in healthcare, including patients and family members, Interdisciplinary teams, and health institutions are susceptible to the implications of adverse events and near misses. Busch et al. (2020) contend that patients and families are the first victims of these incidences since they bear the first-hand effects, including deaths, psychological distress, increased financial burden, and anxiety.
For example, inadvertent use of wrong neuromuscular blocking agents (NMBAs) when preparing for an operation can lead to death and other adverse consequences. Family members may feel aggrieved when their loved ones endure the ramifications of medication errors. Therefore, it is essential to provide psychological and emotional support to the aggrieved family members and provide them with necessary information regarding care processes.
On the other hand, healthcare professionals in an interdisciplinary team are the second victims of the subsequent effects of adverse events and near misses. For instance, nurses, physicians, medical assistants, and nurse assistants are responsible for safeguarding patient safety by ensuring safer medication administration processes. When adverse events occur, healthcare professionals become traumatized and lose confidence in their professional duties.
According to Busch et al. (2020), care providers experience various psychological and psychosomatic symptoms in the aftermath of adverse events and near misses, including anxiety, sleeping difficulties, and disturbing memories. The prevalence of these concerns in the aftermath of an adverse event prompt healthcare institutions to develop appropriate measures for enhancing coping capacity, including providing psychological and social support to care providers, changing the workplace attitude, and emphasizing defensive medicine.
Finally, health institutions are the third victims in an aftermath of adverse events. Liukka et al. (2020) argue that healthcare organizations should develop strategies to reduce the effects and consequences of adverse events, including supporting the first and second victims, providing a complete and genuine apology after adverse events and near misses, and approaches to prevent future reoccurrence of these events.
Also, institutions are responsible for implementing patient safety training, developing coping strategies, and implementing quality improvement initiatives (Liukka et al., 2020). Adverse events can tarnish an organizational reputation, discouraging the patients from seeking treatment at a particular hospital. Finally, Medicaid and Medicare services do not cover most preventable errors, meaning hospitals are susceptible to losing a significant amount of reimbursement amount.
Analyzing the Interprofessional Team’s Responsibilities and Actions to Create a Culture of Safety
An interdisciplinary team comprising physicians, nurses, organizational leaders, and medical assistants is responsible for preventing adverse events and near misses by developing a culture of safety. According to Memon (2022), collaborative strategies for preventing adverse events include maintaining effective communication between healthcare professionals, educating and training care providers, and installing high-quality equipment that promotes process efficiency and accuracy.
Physicians are responsible for educating nurses and medical assistants on appropriate strategies for medication management, while the organizational leaders should update medication management systems, provide up-to-date clinical guidelines, and integrate advanced technologies such as automated drug-distribution cabinets and electronic health records (EHRs). On the other hand, nurses and medical assistants are responsible for assessing patients’ needs and following clinical guidelines to ensure safer medication management processes.
Quality Improvement Technologies
Integrating advanced technologies in clinical practices emerges as a profound strategy for preventing adverse events and near misses, as well as creating a culture of safety. At the organizational level, installing automated drug-distribution cabinets and leveraging hospital dashboards are proven approaches for enhancing patient safety and improving organizational performance.
Ruutiainen et al. (2021) contend that automated dispensing cabinets enable care providers to identify and safely store look-alike, sound-alike medicines through computer-controlled storage and tracing properties and barcode-scanning technology. As a result, this technology is an essential component of closed-loop medication management systems, where technology supports safe medication administration, reducing incidences of medication errors.
On the other hand, leveraging information in the organizational dashboard, including quality indicators and performance metrics provide opportunities for improved performance and benchmarking. According to Kuznetsova et al. (2021), dashboards enable healthcare professionals to visualize large quantities of up-to-date data and to facilitate clinical operational, and strategic decision-making. In essence, visualizing key performance indicators (KPIs) in a dashboard format can decrease time spent on collecting data, reducing the time for task initiation and completion, and improving knowledge of clinical processes.
Relevant Metrics of Quality Improvement
Undoubtedly, dashboard metrics regarding key performance indicators (KPIs) are valuable content in a hospital dashboard. National health organizations such as the Agency for Healthcare Research and Quality (AHRQ) have established metrics for various dimensions of care quality, including patient safety, prevention quality, and pediatric care quality.
These metrics can apply to the emergency department and operational units, yielding various performance indicators, including the number of deaths among patients undergoing coronary artery bypass graft surgery, the prevalence of medication errors, and incidences of adverse events and near-misses (AHRQ, n.d.). The hospital’s surgical unit can include additional KPIs in the dashboard, including risks of drug interactions, the number of successful operations, patient length of stay, and target time for initiating and concluding operations.
Quality Improvement Initiative to Prevent Adverse Events and Near-Misses
The hospital implements to PDSA (Plan-Do-Study-Act) quality improvement model to promote patient safety and improve care quality. This framework entails identifying issues, formulating interventions or theories of change, defining success metrics, putting plans into action, and leveraging analytics to implement and sustain change (AHRQ, 2020). This qualitative improvement framework is universally accepted as a model for implementing change and sustaining new interventions. In the context of preventing adverse events and near misses, it is essential to use the PDSA in assessing their root causes, and risk factors, and implementing evidence-based preventive interventions.
Since the organization has encountered various discrepancies when using the PDSA model to improve care quality, it is essential to incorporate advanced approaches, including new technologies and hospital dashboard metrics to prevent adverse events and near misses. Also, the organization should emphasize interventions for enhancing care providers’ knowledge and awareness of medication administration processes, including care provider training and educational programs, effective communication and delegation, and the development of an effective reporting system.
Conclusion
Undeniably, adverse events and near misses pose a significant threat to patient safety and result in multiple implications for healthcare stakeholders. As a result, implementing quality improvement initiatives such as leveraging dashboard metrics, installing advanced technologies, and knowledge enhancement interventions can significantly reduce the prevalence and incidences of adverse events and near misses. Also, organizations should emphasize assessing the root causes, training employees, improving communication, and transforming reporting systems to create a culture of safety.
References
- Agency for Healthcare Research and Quality. (n.d.). AHRQ quality indicators toolkit fact sheet on inpatient quality indicators what are the inpatient quality indicators? https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/complete_qitoolkit.pdf
- Agency for Healthcare Research and Quality. (2020). Section 4: Ways to approach the quality improvement process (page 1 of 2). https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/index.html
- Busch, I. M., Moretti, F., Purgato, M., Barbui, C., Wu, A. W., & Rimondini, M. (2020). Dealing with adverse events. Journal of Patient Safety, 16(2), e51–e60. https://doi.org/10.1097/pts.0000000000000661
- Cook, D., & Simons, D. J. (2020). Neuromuscular blockade. Stat Pearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538301/
- Kuznetsova, M., Frits, M. L., Dulgarian, S., Iannaccone, C., Mort, E., Bates, D. W., & Salmasian, H. (2021). An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting. JAMIA Open, 4(4). https://doi.org/10.1093/jamiaopen/ooab096
- Liukka, M., Steven, A., Vizcaya Moreno, M. F., Sara-aho, A. M., Khakurel, J., Pearson, P., Turunen, H., & Tella, S. (2020). Action after adverse events in healthcare: An integrative literature review. International Journal of Environmental Research and Public Health, 17(13), 4717. https://doi.org/10.3390/ijerph17134717
- Memon, S. I. (2022). A retrospective analysis of near-miss incidents at a tertiary care teaching hospital in Riyadh, KSA. Journal of Taibah University Medical Sciences, 17(2), 235–240. https://doi.org/10.1016/j.jtumed.2021.11.014
- Nkurunziza, A., Chironda, G., Mukeshimana, M., Uwamahoro, M. C., Umwangange, M. L., & Ngendahayo, F. (2020). Factors contributing to medication administration errors and barriers to self-reporting among nurses: A review of the literature. Rwanda Journal of Medicine and Health Sciences, 2(3), 294. https://doi.org/10.4314/rjmhs.v2i3.14
- Rodziewicz, T. L., Hipskind, J. E., & Houseman, B. (2021, August 6). Medical error prevention. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/
- Ruutiainen, H. K., Kallio, M. M., & Kuitunen, S. K. (2021). Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. European Journal of Hospital Pharmacy. https://doi.org/10.1136/ejhpharm-2020-002531
NURS FP6016 SimmonsC Assessment 1 Adverse Event or Near Miss Analysis Instructions
Instructions
Prepare a comprehensive analysis of an adverse event or a near miss from your professional nursing experience that you or a peer experienced. Provide an analysis of the impact of the same type of adverse event or near miss in other facilities. How was it managed, who was involved, and how was it resolved? Be sure to:
- Analyze the implications of the adverse event or near miss for all stakeholders.
- Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.
- Evaluate QI actions or technologies related to the event that are required to reduce risk and increase patient safety.
- Evaluate how other institutions integrated solutions to prevent these types of events.
- Incorporate relevant metrics of the adverse event or near miss to support the need for improvement.
- Outline a QI initiative to prevent a future adverse event or near miss.
- Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.
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