NHS-FPX 6016 ASSESSMENT 1
Adverse Event Analysis and Solutions
Patient safety is still very important in healthcare systems, but adverse events still happen, and near misses continue to occur despite better technology and regulations (Bell et al., 2023). Communication problems are a big reason why these things happen. The purpose of this paper is to analyze the implications of the adverse event for stakeholders, investigate the fundamental causes of the event, evaluate quality improvement activities and technologies, and propose a quality improvement program to decrease the likelihood of a similar event occurring in the future.
Adverse Event/Near Miss
The chosen near miss happened in an intensive care medical-surgical unit when medication was given incorrectly. A patient with several health problems and high-risk medications almost got the wrong amount because the prescribing provider, pharmacist, and bedside nurse did not communicate clearly during the handoff. There was a misunderstanding regarding the electronic order because a verbal clarification was not provided during the shift change. The bedside nurse noticed the inconsistency while the barcoded drug was being administered, and she immediately put a stop to the administration process. Despite the fact that no patient was harmed, the incident revealed flaws in the processes of medication safety and communication between physicians and other medical professionals. This near miss is crucial since errors of a similar nature regularly result in substantial harm (Ahsani-Estahbanati et al., 2022). This highlights the necessity of systematic quality improvement in order to improve patient safety and prevent future unfavorable outcomes.
Implications
Even though there was no physical harm, the patient was still at a high risk for dangerous side effects if the medication error had been made. Near misses can induce anxiety, erode trust, and raise ethical problems regarding transparency and disclosure, even when their intended purpose is to prevent harm (Bell et al., 2023). Patients and their families may doubt the trustworthiness of care processes, which can affect their long-term trust in the healthcare system and how safe, responsible, and honest professionals are seen to be.
The nursing staff commonly experiences moral discomfort and enhanced professional accountability as a result of near misses. Nurses can experience emotional stress and burnout due to the dread of disciplinary action or legal implications, even when they have successfully minimized the risk of injury (Ahsani-Estahbanati et al., 2022). These events call into question beliefs about having enough training, staff, and safety measures in place. They also show how important it is to have a fair culture that focuses on learning, system improvement, and group support instead of blaming individuals.
When communication breaks down, it makes it harder for people on an interprofessional team to work together and trust each other. During handoffs and care transitions, the probability of information being lost or misread is increased when roles and duties are not clearly defined within the organization (Bell et al., 2023). Near misses show how important it is for different fields to follow the same communication rules, be responsible for each other, and respect each other to provide safe, organized, and effective patient care in complicated healthcare settings.
In the aftermath of near misses, medical companies are forced to contend with greater liability exposure, higher regulatory scrutiny, and increased reputational risk. These kinds of events show where the system is weak and call into question the idea that current rules and technologies protect people well enough (Ahsani-Estahbanati et al., 2022). In the event that communication gaps are not addressed, it is possible that the corporate culture of safety will be weakened, that accreditation compliance will be threatened, and that sustained commitment to continuous quality improvement and risk reduction activities and initiatives will be hindered.
Root Cause Analysis
The occurrence started with a revision to a medicine order that was made during physician rounds but was only partially noted in the electronic health record. A verbal clarification of the new order was not provided during the shift change, which resulted in ambiguity throughout the process (Bell et al., 2023). In the end, the pharmacist decided to verify the drug despite the fact that the information was incomplete. While the barcoded medication was being administered to the patient, the bedside nurse noticed a disparity, and she was able to successfully intercept the error before the drug was administered to the patient.
Some of the most important procedures that were skipped were the incomplete reconciliation of medications and the ineffective communication between members of the care team during handoffs. A lack of consistency was seen in the implementation of standard protocols that necessitated closed-loop communication and comprehensive documentation verification (Lindén-Lahti et al., 2022). The absence of a planned and enforced handoff process allowed key information gaps to continue to exist, which increased the risk of errors occurring despite the presence of many safety checkpoints that were designed to avoid adverse events connected to medicine.
Human factors such as cognitive exhaustion, time constraints, and the assumption that other members of the team have checked the sequence were among the root reasons. Problems at the system level included restrictions inside the electronic health record as well as fragmented workflows that made it difficult to communicate information clearly (Ahsani-Estahbanati et al., 2022). Additional elements that contributed to the near miss were those that were associated with the culture of the organization. These factors included the normalization of workarounds and inconsistent adherence to communication standards.
There is still a lack of clarity surrounding who is responsible for clarifying drug orders and whether or not comparable near misses are consistently reported within the company. The lack of detailed documentation made it difficult to conduct a comprehensive analysis of the communication exchanges that took place between members of the team (Ahsani-Estahbanati et al., 2022). An improved awareness of system vulnerabilities and the ability to direct focused quality improvement measures would be achieved by the implementation of enhanced reporting mechanisms, a more distinct delineation of roles, and extra data on the success of handoffs.
Evaluation of Quality Improvement Actions and Technologies
At the time of the near miss, a number of quality improvement initiatives and technologies were already in place. These included barcode drug administration, electronic health record warnings, and standardized handoff tools, which included SBAR. Improvements in documentation accuracy, verification of patient identity, and promotion of organized interprofessional communication throughout transitions of care are the three main components of these treatments, which are meant to reduce the number of pharmaceutical errors that occur (Lindén-Lahti et al., 2022).
Even though these technologies improve patient safety, their usefulness is restricted due to the inherent difficulties associated with workflow and inconsistent application. It is common for clinicians to become less receptive to EHR warnings as a result of alert fatigue, whereas compliance with SBAR varies from discipline to discipline (Pruitt et al., 2023). Despite the fact that barcode medicine administration is able to efficiently intercept errors at the bedside, it does not address communication failures that occur upstream. This highlights the gaps that exist between technical safeguards and evidence-based treatment procedures.
For the purpose of providing objective evidence in support of the necessity of improvement, metrics such as medication mistake rates, the frequency of reporting near-misses, and patient safety indicators are utilized. When compared to other institutions of a similar nature, benchmarking frequently indicates that near misses are not reported. Recurring communication-related errors emphasize the significance of conducting targeted quality improvement activities focused on enhancing communication dependability and resolving system-level vulnerabilities (Lindén-Lahti et al., 2022). These initiatives should be implemented in order to solve the recurring errors.
The evaluation criteria for quality improvement initiatives should include measurable reductions in medication errors and near misses, increased compliance with reporting and handoff processes, and favorable feedback from staff members regarding the use of the system. The outcomes of patient safety, such as a reduction in the number of harm occurrences and an increase in the continuity of treatment, are crucial indicators (Pruitt et al., 2023). This is whether or not interventions effectively enhance safety and support sustainable organizational improvement.
Quality Improvement Initiative Proposal
Enhancing interprofessional communication during drug ordering and handoffs is the primary emphasis of the quality improvement program that has been proposed. This will be accomplished through the use of standardized procedures that are supported by technology. In order to decrease uncertainty and guarantee shared accountability across disciplines, evidence-based practices would be integrated. These practices would include required SBAR documentation inside the EHR as well as real-time drug clarification checkpoints (Ye, 2023).
Interprofessional education sessions, training based on simulations, and new regulations that mandate consistent handoff paperwork would all be included in the implementation process. When it comes to reinforcing expectations and allocating resources, having the backing of leadership and engaging stakeholders is necessary (Ye, 2023). It would be beneficial to provide continuous feedback and coaching in order to enable sustained adoption and stress communication as a shared responsibility for patient safety.
Possible obstacles include opposition from staff members as a result of the perceived strain on workflow and worries regarding the increased amount of time required for paperwork. Implementation may be affected by resource constraints as well as conflicting priorities. When these perspectives are addressed by staff participation, pilot testing, and clear communication, it is possible to strike a compromise between concerns regarding efficiency and evidence proving significantly improved safety outcomes (Fuller et al., 2022).
The anticipated results include an increase in the dependability of communication as well as a measurable decrease in the number of adverse events and near misses that are associated with medicine. It is also anticipated that the effort will encourage consistent adherence to established communication procedures and will boost staff confidence in the protocols that are used to ensure the safety of drug operations (Fuller et al., 2022). These changes should, over time, promote the organizational culture of safety by promoting shared accountability, interdisciplinary collaboration, and proactive risk identification before patient harm occurs. This should be accomplished by the implementation of these improvements.
Conclusion
The findings of this investigation provide insight into how communication breakdowns contribute to medication-related near misses and vulnerabilities in the system. To reduce risk, proactive quality improvement projects based on methods that have been shown to work are necessary. Healthcare groups can improve patient safety, cut down on mistakes that could have been avoided, and build a strong culture of safety by using technology, standard communication, and collaboration between professionals.
References
Ahsani-Estahbanati, E., Gordeev, V. S., & Doshmangir, L. (2022). Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of systematic reviews. Frontiers in Medicine, 9, 875426. https://doi.org/10.3389/fmed.2022.875426
Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17–18), 5445–5460. https://doi.org/10.1111/jocn.16620
Fuller, A. E. C., Guirguis, L. M., Sadowski, C. A., & Makowsky, M. J. (2022). Evaluation of medication incidents in a long-term care facility using electronic medication administration records and barcode technology. The Senior Care Pharmacist, 37(9), 421–447. https://doi.org/10.4140/tcp.n.2022.421
Lindén-Lahti, C., Kivivuori, S., Lehtonen, L., & Schepel, L. (2022). Implementing a new electronic health record system in a university hospital: The effect on reported medication errors. Healthcare, 10(6), 1020. https://doi.org/10.3390/healthcare10061020
Pruitt, Z. M., Kazi, S., Weir, C., Taft, T., Busog, D., Ratwani, R., & Hettinger, A. Z. (2023). A systematic review of quantitative methods for evaluating Electronic Medication Administration Record and Bar-Coded Medication Administration usability. Applied Clinical Informatics, 14(01), 185–198. https://doi.org/10.1055/s-0043-1761435
Ye, J. (2023). Patient safety of perioperative medication through the lens of digital health and artificial intelligence. JMIR Perioperative Medicine, 6, e34453. https://doi.org/10.2196/34453
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NHS-FPX 6016 ASSESSMENT 1
Health care organizations strive to create a culture of safety. Despite technological advances, quality care initiatives, oversight, ongoing education and training, legislation, and regulations, medical errors continue to be made. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. Many errors are attributable to ineffective interprofessional communication.
Overview
The goal of this assessment is to allow you to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a QI initiative to prevent future incidents. It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself in as a health care professional.
Health care organizations strive for a culture of safety. Yet, despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation, and regulations, medical errors continue to occur. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation.
Historically, medical errors were reported and analyzed in hindsight. Today, QI initiatives attempt to be proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by new technologies and reporting metrics, adverse events and near misses can provide insight into potential ways to improve care delivery and ensure patient safety.
For clarification, the National Quality Forum (n.d.) defines the following:
- Adverse event: An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.
- Near miss: An event or a situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention.
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 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.
Be sure your analysis addresses all of the above points. You may also want to read the Adverse Event or Near Miss Analysis Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Adverse Event or Near Miss Analysis [DOCX] document for additional clarification about things to consider when creating your assessment.
Additional Requirements
Your assessment should also meet the following requirements:
- Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page or References section.
- Number of references: Cite a minimum of three sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master’s Program (MSN) Library Guide for guidance.
- APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
- Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.
- Analyze the implications of an adverse event or a near miss for all stakeholders.
- Analyze the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis.
- Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.
- Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
- Evaluate and identify quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.
- Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
- Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.
Reference
National Quality Forum. (n.d.). NQF patient safety terms and definitions. http://www.qualityforum.org/Topics/Safety_Definitions.aspx
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
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Criterion 1
Analyze the implications of an adverse event or a near miss for all stakeholders.
Distinguished
Analyzes the implications of an adverse event or a near miss for all stakeholders, and identifies assumptions on which the analysis is based.
Proficient
Analyzes the implications of an adverse event or a near miss for all stakeholders.
Basic
Lists possible impacts of an adverse event or a near miss for stakeholders, but fails to analyze their short- or long-term implications for the stakeholders.
Non Performance
Does not list the implications of an adverse event or a near miss for all stakeholders.
Criterion 2
Analyze the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis.
Distinguished
Analyzes the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the analysis).
Proficient
Analyzes the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis.
Basic
Lists the missed steps or protocol deviations related to an adverse event or a near miss, but fails to analyze how they led to the adverse event or near miss.
Non Performance
Does not list the missed steps or protocol deviations related to an adverse event or a near miss.
Criterion 3
Evaluate and identify quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.
Distinguished
Evaluates and identifies quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety. Identifies criteria to evaluate the actions or technologies discussed.
Proficient
Evaluates and identifies quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.
Basic
Lists quality improvement actions or technologies related to an event to potentially reduce risk or increase patient safety, but fails to evaluate how those technologies were used, or how they could be more usefully employed.
Non Performance
Does not evaluate or identify quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.
Criterion 4
Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.
Distinguished
Outlines a quality improvement initiative to prevent a future adverse event or near miss, and impartially considers conflicting data and other perspectives.
Proficient
Outlines a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.
Basic
Attempts to outline a quality improvement initiative to prevent a future adverse event or near miss, but it is not clear that quality improvement suggestions are based on research or best practices.
Non Performance
Does not outline a quality improvement initiative to prevent a future adverse event or near miss.
Criterion 5
Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.
Distinguished
Conveys clear purpose, in a tone and style well-suited to the intended audience. Supports assertions, arguments, and conclusions with relevant, credible, and convincing evidence. Exhibits strict and nearly flawless adherence to organizational, professional, and scholarly writing standards, including APA style and formatting.
Proficient
Conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.
Basic
Conveys purpose, in an appropriate tone or style. Clear, effective communication is inhibited by insufficient supporting evidence and/or minimal adherence to applicable writing standards.
Non Performance
Does not convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and writing scholarly standards.