Adverse Event or Near-Miss Analysis.

Write a 5–7-page a comprehensive analysis on an adverse event or near miss from your professional nursing experience. Integrate research and data on the event and use as a basis to propose a quality improvement (QI) initiative in your current organization. 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. Adverse Event or Near-Miss

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Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. SHOW LESS The goal of this assessment is to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a quality improvement initiative to prevent future incidents. By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Adverse Event or Near-Miss Analysis.Competency 2: Plan quality improvement initiatives in response to routine data surveillance. Analyze the missed steps or protocol deviations related to an adverse event or near miss. Analyze the implications of the adverse event or near miss for all stakeholders. Outline a quality improvement initiative to prevent a future adverse event or near miss. Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures. Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement. Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care. Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.Adverse Event or Near-Miss Analysis.

Adverse Event or Near-Miss Analysis

Healthcare organizations have prioritized service delivery and quality improvement. The US government has even gone to the extent of making certain adverse events illegal. Despite efforts to curb adverse events and near misses, the American health system continues to report an unprecedented increase in the number of these events. Studies have established that adverse events are the primary reason for health complications causing extended hospitalization, disabilities, and in some cases death. Adverse Event or Near-Miss Analysis.Clinical researchers attribute a majority of adverse events and near misses in the US to communication issues and psychiatric disorders. Communication mishaps between patients and health providers increase the risk of adverse events. Medication errors are also to blame for a significant percentage of adverse events and near misses. This analysis picks out an adverse event I witnessed during nursing practice and identifies a quality improvement initiative to address the issue. Adverse Event or Near-Miss Analysis.

Identification of the Adverse Event/Near-Miss

The adverse event in question highlights a medication error at the prescription stage at the Mary Leakey Renal Center. The occurrence is preventable as it relates to drug dosage and patient medication. The patient in the scenario is a 72-year-old man, Ronald Drake, with kidney issues and was in dire need of kidney dialysis. His treatment procedure included an initial administration of human albumin, after which Mr. Drake contracted dyspnea. After some time, the man developed breathing complications and the oxygen saturation dropped to about 75% causing tachycardia issues. The health provider attending to Ronald thus prescribed epinephrine, following which the patient had to be accorded intensive care. A detailed medical examination revealed that Mr. Drake was traumatically allergic to Human Albumin, a condition known as anaphylaxis. Adverse Event or Near-Miss Analysis.

Analysis of the Adverse Event/Near-Miss

The adverse event is a result of an unforeseen medication error during kidney dialysis. The health providers in the organization deviated from the relevant protocol, which involves examination for allergies, thus, warranting the adverse event or near miss (Jylhä, Bates, & Saranto, 2016). The medication error resulted in anaphylaxis, which is a life-threatening reaction that requires immediate medical attention. In the course of ill-treatment, anaphylaxis can be fatal. The condition, however, was adequately managed to evade death. The medication mishap is a clear indication of the need for intensifying clinical research, medical resources, and medication prescription to enable healthcare providers to establish probable drug interactions and reactions beforehand. Adverse Event or Near-Miss Analysis.

The adverse event/near miss in question is preventable since medication errors are identifiable and can be avoided. The physician in charge administered Human Albumin, on the first instance, while the patient was undergoing dialysis. Such a prescription infers that the clinician assumed that Human Albumin works well with the patient and that the patient had no record of an allergic reaction to the drug. From my observation, the healthcare provider did not perform any tests to verify the suitability of the drug before administering it to Mr. Drake. The physician did not also see a reason to mention the prescription to the patient or their caregivers but went ahead and injected Mr. Drake with Human Albumin.
The medical mishap at hand can be attributed to a lack of communication between the patient and providers, and perhaps sheer ignorance on the part of the healthcare providers (Jylhä, Bates, & Saranto, 2016). Adverse Event or Near-Miss Analysis.The clinician’s utter confidence while he made the drug prescription and their ignorance towards the possibility of a drug reaction could be subject to inadequate exposure during nursing education and training. Also, the nurse who administered the medication did not at any point suspect that the patient could be affected by Human Albumin even at his (Mr. Drake’s) age. The clinician and the nurse could have easily avoided the mishap by involving the patient or their caregiver. In this case, the near-miss would have been fatal if the right intervention would not have been provided in due time.Adverse Event or Near-Miss Analysis.

Implications of the Adverse Event

Every health system, including that of the US, is prone to experience adverse events or near misses related to unforeseen errors. Such events have significant impacts on medical personnel, patients, their families, and the healthcare organization in question. The effects of adverse events may be financial, social, psychological, and/or emotional, depending on the severity of the case. The financial impacts of adverse events include the hospitalization costs incurred while the social impacts involve the patient’s state of mind and their inability to associate with family and friends when complications arise. Adverse Event or Near-Miss Analysis.The psychological aspect covers the mental effects of extended hospital stays and worsening health conditions on the patient and their family. The emotional aspect factors in both the healthcare providers and the patient and their caregiver. The physician, for instance, may harbor feelings of anger, anxiety, guilt, and stress following the near-miss.
Research places the patient and their family at the forefront when discussing the impacts of adverse events or near misses.Adverse Event or Near-Miss Analysis. The case at the Mary Leakey Renal Center, for instance, conferred enormous emotional distress to the patient and his family. For a moment, the family must have been unsure of the patient’s capacity to recover from the allergic reaction as he was transferred into the Intensive Care Unit. Since studies demonstrate that the outcome of a majority of medical errors is often fatal, Mr. Drake’s family was terrified that they could lose their person to the adverse event. The medical error could have also been traumatic for the family, especially after they realized that the patient remained unconscious even after the medication, which was expected to save the situation, was administered. Adverse Event or Near-Miss Analysis.

Although the nurses and other medical practitioners at the Mary Leakey Renal Center were squarely to blame for the prescription and medication error, these people are categorized as secondary victims of the incident. The fields of medicine and nursing call for utmost precision and the need to eliminate the possibility of such errors occurring (Furukawa et al., 2020). Adverse Event or Near-Miss Analysis.The psychological impact of the medication error thus spreads to the respective healthcare providers raising the risk of such feelings as confusion, depression, guilt, and self-doubt (Ferrús et al., 2016). Research has also proven that medical errors primarily drive suicidal thoughts and attempts among medical personnel (Ferrús et al., 2016). It is thus difficult to ignore these medics when analyzing the impacts of the adverse event in question. The healthcare organization also features as the tertiary victim since the Mary Leakey Renal Center’s reputation is at stake. Adverse Event or Near-Miss Analysis.

Quality Improvement Initiatives

Healthcare organizations are constantly making efforts towards improving patient safety and service quality. The first technique I would recommend for the Mary Leakey Renal Center is the incorporation of the Computerized Physician Order Entry (CPOE) into their system. Adverse Event or Near-Miss Analysis.The CPOE is designed to provide accuracy in health record entry thus reducing chances for such errors as medication, surgical, and drug reactions. The primary motive for the development of CPOE was to cut down cases of incorrect medications and prescription errors, dosage issues, and provide a background for checking for patients’ allergic reactions. The device is tied to the efficiency of Electronic Health Records (EHR) and as such has promising results (Furukawa et al., 2020). Electronic health records have been proved to reduce medical errors significantly hence the notion.Adverse Event or Near-Miss Analysis.

The analysis focuses on performance determinants towards improving the state of affairs at the Mary Leakey Renal Center. A majority of healthcare providers, including those at the organization, make use of manual health records leaving so much room for medication errors. EHR and CPOE are automated thus minimizing the possibility of missing out on patient information. Besides, these tools provide room for modification and improvement to cater to risk assessment and management, patient safety, and improved medical screening (Furukawa et al., 2020). Adverse Event or Near-Miss Analysis.The highlighted areas, coincidentally, at the Mary Leakey Renal Center are the ones that require tremendous effort towards improvement. There is also a need to enhance the patient-provider ratio at the organization to ensure that each patient receives sufficient provider attention and care. The necessity for improving inter-professional communication at the health institution is also imminent. The organization may host seminars and team-building activities to boost team cohesion thus enhancing communication.Adverse Event or Near-Miss Analysis.

Conclusion

An adverse event or near-miss refers to a medical mistake that significantly impacts the patient, healthcare providers, and to some extent, the health organization. While studies have established the inevitability of adverse events, these mistakes are often foreseeable and preventable. Providing the highest service quality can be a challenge hence the need for quality improvement initiatives. There is a need for enhancing team cohesion and patient-provider communication as effective communication is key for efficient health delivery. It is also important that the organization incorporates electronic health records and computerized physician record entry into their system to minimize medical errors, thus, ensuring quality improvement.Adverse Event or Near-Miss Analysis.