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

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In healthcare, ensuring patient safety and providing optimal care is paramount. Adverse events and near misses highlight in “NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis” the critical need for continuous quality improvement initiatives (Isaksson et al., 2021). This assessment focuses on a case study centered around patient John Smith, exploring the circumstances, sequence of events, and root causes that led to an adverse event. By analyzing this scenario, evaluating existing quality improvement technologies, and considering evidence-based practices, we aim to uncover valuable insights into preventing similar incidents in the future. This assessment underscores the significance of proactive measures, interprofessional collaboration, and the application of best practices to safeguard patient well-being and enhance healthcare outcomes. 

Patient Scenario

John Smith, a 55-year-old with heart issues, was admitted to Villa Hospital for chest pain. Amidst understaffing and a high workload, Nurse Lisa, stressed and overwhelmed, mistakenly administered nitroglycerin meant for another patient. John’s blood pressure dropped, and though the error was caught, his condition worsened due to inadequate monitoring. A delayed arrhythmia detection led to a code blue, and he was transferred to the ICU. Despite efforts, John’s heart damage was irreparable, and he passed away on Day 6. This tragic event highlights the dangerous mix of staffing shortages, nurse stress, and inadequate monitoring, emphasizing proper nurse-patient ratios, stress management, and a robust patient safety culture. 

Implications of the Adverse Event for Stakeholders

The adverse event involving John Smith carries significant implications for all stakeholders involved in his care. The consequences for the patient and his family were tragically severe, as John lost his life due to a chain of errors and delays in his treatment. This sudden loss not only devastated the family emotionally but could also lead to a lasting distrust in the healthcare system, impacting their future interactions with healthcare professionals.

The interprofessional team, including Nurse Lisa and other healthcare providers, experienced immediate emotional distress after the event. Feelings of guilt, anxiety, and grief were likely to have occurred. In the long term, this incident may catalyze changes within the team dynamics. It could lead to reevaluating protocols, fostering an environment of enhanced communication and collaboration to prevent similar incidents from occurring in the future. Healthcare professionals might become more vigilant and open to discussing errors to facilitate improvements in patient safety (Rigamonti & Rigamonti, 2021).

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

The healthcare facility faces not only reputational damage but also potential legal consequences due to the unfortunate outcome of medical errors. Regulatory bodies might closely scrutinize the facility’s operations and protocols, possibly affecting its accreditation status. The event could trigger a series of assessments and improvements to ensure patient safety measures are strengthened (Behrens et al., 2022).

Within the community, incidents such as NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis could erode trust in the healthcare system. Word-of-mouth discussions and media coverage might impact community members’ perceptions and choices when seeking medical care. The incident’s effects could ripple beyond the hospital, shaping the community’s perspective on healthcare institutions in general.

Adverse Event or Near-Miss Analysis

Following the adverse event, the interprofessional team must take a proactive approach to address the situation. A thorough root cause analysis is crucial to identify the underlying factors contributing to the errors. Reviewing and revising protocols, prioritizing training in stress management and proper medication administration, and addressing staffing shortages are measures the team must undertake collectively (Laatikainen et al., 2021).

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

Responsible parties include frontline healthcare providers like Nurse Lisa and higher-level management, who must ensure adequate staffing and support mechanisms. The impact of the incident has likely led to changes in workflows, stricter adherence to protocols, and potentially altered reporting mechanisms to facilitate a more transparent and proactive approach to patient safety (Nantsupawat et al., 2021).

Adverse Event with Root Cause Analysis

The sequence of events that led to the adverse event involving John Smith can be analyzed through a root cause analysis. The event resulted from a series of missed steps and protocol deviations in his medical management, exacerbating the impact of his underlying condition. The missed steps and deviations began with Nurse Lisa’s crushing workload due to understaffing. This led to the first error – administering the wrong medication, nitroglycerin, due to stress-induced cognitive overload. Subsequently, inadequate monitoring of John’s condition due to Nurse Lisa’s multiple responsibilities delayed the recognition of a developing arrhythmia (Raeissi et al., 2022).

NURS FPX 6016 Assessment 1

The adverse event stemmed from these protocol deviations in the context of “NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis” rather than solely from John’s underlying heart condition. The sequence of errors amplified the stress on John’s already compromised cardiovascular system, leading to a rapid deterioration of his health. The missed steps failed to provide appropriate medication, timely monitoring, and accurate recognition of critical changes. Nurse Lisa’s cognitive overload and the facility’s staffing shortages contributed to these lapses. Communication breakdowns were also evident as the team failed to identify and rectify the medication error in a timely manner (Hsieh et al., 2021).

Related Assessment: NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal

To prevent this event, effective interprofessional communication is crucial. Regular team briefings, handoffs, and clear protocols could have played a vital role in preventing medication errors. Improved communication channels between nurses, doctors, and other team members would ensure timely intervention and error correction (Hsieh et al., 2021).

The adverse event was partially preventable through proper nurse staffing, stress management support, and stringent medication administration protocols. NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis. While unexpected medical complications can occur, the sequence of errors due to workload, cognitive overload, and communication gaps significantly contribute to the adverse outcome (Behrens et al., 2022).

Knowledge Gaps

There are some knowledge gaps about the specific medications, dosages, and monitoring procedures relevant to John’s case. Additionally, it doesn’t provide clear insights into the underlying heart condition, the nature of the arrhythmia, and how these medical aspects interacted with the protocol deviations to lead to the adverse event.

Evaluation of Quality Improvement Technologies Related to the Event

Healthcare facilities could implement quality improvement measures to mitigate risks and bolster patient safety in response to adverse events involving John Smith. Electronic Medication Administration Records (eMARs) represent a significant technological solution. These systems can help prevent medication errors by providing accurate records and alerts, ensuring that the right patient receives the right medication at the right dose and time. Integrating eMARs seamlessly into the workflow is essential to maximize their effectiveness (Pruitt et al., 2023).

Appropriate Utilization and Training

The successful deployment of such technologies necessitates proper training and education for healthcare staff. Conducting regular training sessions on how to use eMARs effectively and navigate other related systems is vital. Moreover, ensuring that nurses and other healthcare providers are well-versed in the technology can substantially enhance its usefulness and impact (Karnehed et al., 2021).

Patient Monitoring Technologies at Other Institutions

Across different healthcare institutions, a proactive approach involves using real-time patient monitoring systems. Wearable devices that continuously track vital signs allow for the early detection of deteriorating conditions. These systems provide healthcare teams with timely insights, enabling prompt intervention and preventing adverse events (Fuller et al., 2022).

Dashboard Data and Metrics

Within the facility’s dashboard data, metrics related to NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis, medication errors, patient monitoring frequency, patient satisfaction, and readmission rates are crucial. These metrics provide a comprehensive overview of patient outcomes and care quality. By comparing internal data with external benchmarks, healthcare facilities can identify areas for improvement and align their strategies with best practices.

External Research and Data

While specific external data about the exact adverse event might not be available, broader research on the effectiveness of technologies like eMARs and patient monitoring systems can guide improvement efforts. Utilizing insights from the broader healthcare literature can help tailor strategies to prevent future adverse events (Karnehed et al., 2021).

Criteria to Evaluate

To evaluate the discussed actions and technologies, criteria such as effectiveness in reducing errors, ease of integration into existing workflows, staff competency in utilizing the technologies, patient outcomes, and alignment with external best practices should be considered. Comparing internal data trends with external benchmarks can further assess the impact of these measures on patient safety and care quality (Fuller et al., 2022).

Quality Improvement Initiative to Prevent a Future Adverse Event or Near Miss

A comprehensive quality improvement initiative can be implemented to prevent future adverse events. Beginning with a thorough analysis of the incident involving John Smith, the initiative could introduce electronic Medication Administration Records (eMARs) to reduce medication errors by ensuring accurate dosages and timely administration. Standardized protocols for interprofessional communication during medication administration and patient monitoring can also be established to enhance coordination (Cotton et al., 2022).

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

To manage and monitor such incidents, the selected institution engaged in incident reporting, immediate intervention, and post-event analysis. Incident reports were filed to capture errors, followed by a detailed examination to determine root causes and implement preventive measures. Dashboard metrics tracking medication errors, patient monitoring frequency, and patient satisfaction facilitated ongoing monitoring and improvement assessment (Laatikainen et al., 2021). Evidence-based practices support the effectiveness of such initiatives. Research demonstrates that eMARs significantly reduce medication errors, improving patient safety. Real-time patient monitoring technologies have shown success in the early detection of deteriorating conditions, contributing to enhanced outcomes and decreased adverse events.

Applying these principles to prevent future adverse events, such as NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis, entails the implementation of eMARs for accurate medication administration, stress management support for healthcare providers, introduction of wearable patient monitoring devices for timely intervention, and the utilization of dashboard metrics to monitor progress (Cotton et al., 2022).

Conflicting Data

Conflicting data suggests that success with eMARs hinges on proper integration and staff training, while wearable monitoring technologies might face reliability and acceptance challenges. This underscores the need for careful implementation and ongoing evaluation to ensure the effectiveness of these technologies and practices. By combining evidence-based strategies with data-driven insights, healthcare facilities can cultivate a safety culture and minimize adverse events (Tanui, 2022).

Conclusion

John’s case, NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis, exemplifies the critical importance of patient safety and the need for robust quality improvement measures. The sequence of errors, stemming from nurse workload, medication administration, and monitoring lapses, resulted in tragic consequences. Implementing eMARs, enhancing interprofessional communication, and utilizing real-time patient monitoring can mitigate risks. Incident analysis, evidence-based initiatives, and benchmarking are vital for preventing future adverse events. Striking a balance between conflicting data underscores the necessity of thoughtful implementation and continuous evaluation to ensure patient safety.

References 

Behrens, D. A., Rauner, M. S., & Sommersguter-Reichmann, M. (2022). Why resilience in health care systems is more than coping with disasters: Implications for health care policy. Schmalenbach Journal of Business Research. https://doi.org/10.1007/s41471-022-00132-0 

Cotton, K., Booth Richard Booth, R. G., McMurray, J., & Treesh, R. (2022). Understanding health information exchange processes within Canadian long‐term care: A scoping review. International Journal of Older People Nursing. https://doi.org/10.1111/opn.12501 

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 

Hsieh, M.-C., Chiang, P.-Y., Lee, Y.-C., Wang, E. M.-Y., Kung, W.-C., Hu, Y.-T., Huang, M.-S., & Hsieh, H.-C. (2021). An investigation of human errors in medication adverse event improvement priority using a hybrid approach. Healthcare, 9(4). https://doi.org/10.3390/healthcare9040442 

Isaksson, S., Schwarz, A., Rusner, M., Nordström, S., & Källman, U. (2021). Monitoring preventable adverse events and near misses. Journal of Patient Safety, Publish Ahead of Print. https://doi.org/10.1097/pts.0000000000000921 

Karnehed, S., Erlandsson, L.-K., & Norell Pejner, M. (2021). Nurses’ perspectives on an electronic medication administration record in home healthcare: Qualitative interview study (Preprint). JMIR Nursing, 5(1). https://doi.org/10.2196/35363 

Laatikainen, O., Sneck, S., & Turpeinen, M. (2021). Medication-related adverse events in health care—what have we learned? A narrative overview of the current knowledge. European Journal of Clinical Pharmacology. https://doi.org/10.1007/s00228-021-03213-x 

Nantsupawat, A., Poghosyan, L., Wichaikhum, O., Kunaviktikul, W., Fang, Y., Kueakomoldej, S., Thienthong, H., & Turale, S. (2021). Nurse staffing, missed care, quality of care and adverse events: A cross‐sectional study. Journal of Nursing Management, 30(2). https://doi.org/10.1111/jonm.13501 

Pruitt, Z. M., Kazi, S., Weir, C., Taft, T., Busog, D.-N., 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 

Raeissi, P., Aryankhesal, A., Shahidi Sadeghi, N., & Kalantari, H. (2022). Root Cause Analysis (RCA) of adverse events in one of the biggest western Iranian general hospitals: Short communication. Health Scope, 11(4). https://doi.org/10.5812/jhealthscope-118032 

Raisi-Estabragh, Z., & Mamas, M. A. (2022). COVID-19: Health care implications. Cardiology Clinics. https://doi.org/10.1016/j.ccl.2022.03.010 

Rigamonti, D., & Rigamonti, K. H. (2021). Achieving and maintaining safety in healthcare requires unwavering institutional and individual commitments. Cureus, 13(2). https://doi.org/10.7759/cureus.13192 

Tanui, A. K. (2022). Ethical management of incidental findings related to development and use of digital health platforms for older people. www.theseus.fi. https://www.theseus.fi/handle/10024/785923