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

Adverse Event or Near-Miss Analysis

Medical errors on part of the healthcare providers due to lack of attention result in adverse events or near-miss events. These events are preventable errors that can be minimized by providing healthcare providers with additional help through the introduction of technological aid. 

Implications of an Adverse Event 

An adverse occurred in the healthcare setup where I work which resulted in fatalities. The adverse event was due to a medication error on part of the prescriber who had mistakenly administered a drug that led to an instant decrease in blood pressure and the patient underwent severe hypotensive crises which induced a coma in the patient. 

This adverse event hurt the stakeholders (patients and the hospital). Following this incident, many the number of patients who came to receive healthcare services decreased drastically. The hospital began to lose its financial, social, and economic standing as more of its patients started to get healthcare services from other hospitals. 

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

Short-term and Long-term effects for Stakeholders

The short effect is that the patient will be unsatisfied, they will be cautious of the care that they will receive at the hospital and the healthcare providers will be demoralized by their inability to prevent the medication error that endangered the patient’s life. The long-term effect will be the lack of patients willing to require healthcare services from the hospital. In the healthcare system, the investors and owners will go bankrupt and will lose their business as the patient would not require healthcare services from it. 

Assumptions

The analysis is based on the assumption that the healthcare providers due to being overburdened make medical errors that lead to fatalities, mortality, and morbidity rate. As a result, patient dissatisfaction increases and patients refuse to receive treatment from the same hospital. 

The sequence of Events/ Missed Steps 

The sequence of events that led to the adverse event involved the lack of ability of the healthcare providers to evaluate and assess the effect of the drugs which were to be administered to the patients. The cardiologist came, assessed the patient’s emergency condition, and prescribed the drugs that needed to be administered. The cardiologist was in a hurry and needed to attend to other patients, due to which he prescribed the wrong medication (missed step 1). The nurses were instructed to follow the prescription and since they did not have enough knowledge to question the drug prescribed, they blindly administered the patient with medication (missed step 2). 

The medicine which was administered was Sodium Nitroprusside which instantly decreased the patient’s blood pressure and induced a coma. The patient already had low blood pressure and needed treatment for it, instead of prescribing Atropine, the cardiologist prescribed Sodium Nitroprusside which is administered in case of severe high blood pressure. The patient was shifted to ICU (Intensive Care Unit) to nullify the effect of the drug. 

The above-mentioned missed steps were responsible for the adverse event which occurred. The factor which contributed to the adverse event was the overburden of the healthcare providers which resulted in a lack of time management of the healthcare providers. The lack of management resulted in the wrong prescription of the drugs which led to adverse events and endangered the patient’s life. 

Knowledge Gaps

Another missed step was the lack of knowledge of nurses regarding the medication which are prescribed. They do not know the pharmacological and pharmacodynamic effects of the medications and administer them to the patient. As a result, adverse events occur which endanger the life of the patient.

Quality Improvement Actions or Technologies

Quality Improvement (QI) actions are needed to prevent adverse events and near-miss events which endanger the patient’s life. The QI technologies which can be implemented to reduce adverse events include the implementation of an Electronic Health Record (EHR) system. Along with this, the QI action which can be implemented in the healthcare center to reduce the chances of adverse events and medication errors include the education of healthcare providers especially the nurses about the drugs (Holmgren et al., 2020). 

This knowledge will help the nurses to be proficient to an extent that when medications are prescribed the nurses can analyze, assess, and evaluate if the drug prescribed by the physician or the specialist is correct or not. Along with this, the education of nursing staff to be careful, cautious, and active while monitoring the patient. This will allow them to be knowledgeable about the signs and symptoms which correspond to an emergency condition that will amplify due to adverse effects of the medication therapy. This will help to prevent adverse event-led emergencies that increase mortality and morbidity rates for the patients. Both of these QI actions and technologies are required to reduce the risk to the patient’s life and to ensure patient safety (Mardani et al., 2020). 

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

Criteria

The criteria which will be used to evaluate the actions or technologies will be the reduction in the number of medication errors and adverse events which have occurred. The reduction in the frequency of the events will pose criteria for evaluation of the effectiveness and safety of the QI actions and technologies (Gates et al., 2021). 

Quality Improvement Initiative 

The proposed quality improvement initiative to prevent adverse events includes the use of an EHR system. The introduction of the EHR system will help healthcare providers to countercheck the medications which they prescribe. It will help to countercheck the concentration of the drug which are prescribed. Through its updated system, the EHR system will check for interactions that the drug will have, and if it is contraindicated in the patient’s respective patient’s conditions. 

The EHR system will also have an inbuilt alarm or warning system which will ensure that if any adverse event is about to occur or is expected to happen, the EHR system will initiate a series of alarm or warning systems that will warn the healthcare providers about the adverse event. As a result, it will help to prevent adverse events or near-miss events from happening (Vaidotas et al., 2019). 

The EHR system comes equipped with a monitoring system that monitors the health of the patient throughout the therapy session. This allows for the effective prevention of medication errors, adverse events, or near-miss events which may occur. The monitoring system keeps the healthcare providers in the loop of the patient’s condition and ensures no harm is inflicted on the patient’s health (Carayon et al., 2021). 

The healthcare system should also encourage healthcare providers to work in collaboration and communicate with team members to prevent adverse events. They should be paired in teams to encourage counterchecking of each step starting from prescription and dispensing, to administration. All steps should be counterchecked to prevent errors and to ensure that the correct medication is being prescribed, dispensed, and administered (Irajpour et al., 2019). 

Healthcare providers should also be encouraged to learn about the interaction between drugs, their pharmacological pathways, their adverse events, and the patient population which should not be administered these medications. Along with this, education, availability, and accessibility of the antidotes to the medications such be available in the emergency room (ER). All of the necessary lifesaving drugs, machinery, and equipment should be available in the ER to provide the patient with instant care to prevent the degradation of health (Hanson & Haddad, 2022). 

Conflicting Data

Conflicting data regarding the use and implementation of EHR systems in preventing medication errors is that some glitches in the system prevent the effective recognition of medication errors, adverse events, or near-miss events. This hampers the ability of the EHR system to provide safe and quality care sometimes. The EHR system also has privacy protection issues linked to patient information that contribute to the unsafe use of electronic health services (Basil et al., 2022). Another conflicting data is that the healthcare providers are not willing to learn about the technological aid to increase the effectiveness of the therapy and to prevent medication errors. 

Conclusion

Adverse events and near-miss events occur due to the lack of attention from healthcare providers. These events are preventable and can easily be prevented from happening if healthcare providers are educated about the importance of double-checking and the introduction of an EHR system. 

References 

Basil, N. N., Ambe, S., Ekhator, C., & Fonkem, E. (2022). Health records database and inherent security concerns: A review of the literature. Cureus14(10), e30168. https://doi.org/10.7759/cureus.30168

Carayon, P., Du, S., Brown, R., Cartmill, R., Johnson, M., & Wetterneck, T. B. (2017). EHR-related medication errors in two ICUs. Journal of Healthcare Risk Management: The Journal of The American Society for Healthcare Risk Management36(3), 6–15. https://doi.org/10.1002/jhrm.21259 

Gates, P. J., Hardie, R. A., Raban, M. Z., Li, L., & Westbrook, J. I. (2021). How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? a systematic review and meta-analysis. Journal of the American Medical Informatics Association: JAMIA28(1), 167–176. https://doi.org/10.1093/jamia/ocaa230 

Hanson, A., & Haddad, L. M. (2021). Nursing rights of medication administration. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560654/ 

Holmgren, A. J., Co, Z., Newmark, L., Danforth, M., Classen, D., & Bates, D. (2020). Assessing the safety of electronic health records: A national longitudinal study of medication-related decision support. BMJ quality & safety29(1), 52–59. https://doi.org/10.1136/bmjqs-2019-009609 

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 Promotion8, 196. https://doi.org/10.4103/jehp.jehp_200_19 

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

Mardani, A., Griffiths, P., & Vaismoradi, M. (2020). The role of the nurse in the management of medicines during transitional care: A systematic review. Journal of Multidisciplinary Healthcare13, 1347–1361. https://doi.org/10.2147/JMDH.S276061 

Vaidotas, M., Yokota, P. K. O., Negrini, N. M. M., Leiderman, D. B. D., Souza, V. P., Santos, O. F. P. D., & Wolosker, N. (2019). Medication errors in emergency departments: is electronic medical record an effective barrier? Einstein (Sao Paulo, Brazil)17(4), eGS4282. https://doi.org/10.31744/einstein_journal/2019GS4282 

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