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

Amy Braden

Nurs FPX 6016

Capella University

Professor Yuliya Malishkin

April 9, 2025

Healthcare: A bad or close-knock-out event review is valued in healthcare quality and protection enhancement. By means of evaluation, healthcare companies enhance controls and minimize the unsafe effects on patients (Bhati et al., 2023). In addition, Nurs FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis review enhances the staff education application diagram and allows health teams to work cooperatively. Its objective is to ascertain the overall reason for a near-leave-out event and the steps taken such that it will minimize the risk of hazardous exercise of care.

Patient Scenario

There was a near-elimination mishap, a prescribing mistake, in the local health clinic where the patient had almost been given the incorrect prescription due to a nurse having scribbled it down incorrectly. The incorrect patient was administered the incorrect drug due to the facts not being confirmed by the nurse. One of the nurses would have wished to have made the mistake before any horrific consequences ensued. She reviewed the patient’s record and saw the mistake in the note. That is a display of how important documentation and word reports of some of the medical caregivers are. eMAR tool laptop software may be beneficial to infected men or women. It has the capability to reduce the risk of drug errors by utilizing mechanisms such as nurses and providing real-time right of entry. Tool software programs will reduce drug mistakes in nursing care, enhance function, and optimize patients’ health.

Implications of the Event for Stakeholders

Confidence and coordination in the organization can be lost. Beyond money and emotional damages, if the physical health of the male or female victim worsens, the gymnasium is responsible, and this affords possible criminal charges. The aforementioned nurse can further stand to be jeopardized professionally by being disciplined, suspended, or having his/her license revoked or prosecuted as a scammer. The victim character also gets hurt by ensuing augmented morbidity or even death, which supports the tragedy (Rodziewicz et al., 2023). Usually, incidents help in supporting the value of good safety cultures, endured training, and tool-level accountability as a way of developing the safety of all involved and ultimately limiting opportunities.

Responsibilities of the Interprofessional Team

All physicians, pharmacists, guide staff, nurses, and city clinic personnel have some responsibility for the care of the near-miss over time. It is their job to ensure patient safety through the positive process of clean communication, accurate documentation, and protocol compliance. The corporation also bears responsibility for documenting the incident through the use of the clinic reporting tool once the incident is understood. They must perform a root cause analysis, an excellent tool in contributory cause identification. Below is what must be done: The nurse’s initial reaction must be charted, and branch-to-department observed orders.

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

The pharmacy staff must re-read the dispensing coverage. Nurses double-check drug orders. Management needs to be translated into a norm of ongoing familiarization and open communication. The business organization must function as a body to enforce or impose policies on such an error (Zajac et al., 2021). Training of digital infrastructures with eMAR must be conducted. Communication and collaboration must be employed. With coordination, the business organization shall also be able to ensure that procedures are automated, the risk may be minimized, and safety can be maximized for all patients.

Measures and Impact on Stakeholders

After the near-miss over an event at a town health facility, there were some measures that should have been taken in order to prevent such mistakes. Treatment orders need to be rechecked by utilizing the nurses’ assistance. They need to cross-check – move prescriptions from the affected man or woman’s files prior to managing. Implementing or acquiring the eMAR tool is of major significance. Continuous learning of the framework of workers and employees in tight treatment practices is required (Singh et al., 2021). Stakeholders were professionally and emotionally impacted subsequent to the incident. The collaborating nurse is also duty-bound but also empowered to report. The personnel are more responsive and vigilant. Procedure-based reporting is more intentional, with more documentation and alerting. In Nurs FPX 6016 Assessment 1 hospital management needs to accord maximum priority to equipment redesign and safety programs to render control of treatment more desirable (Singh et al., 2021). Overall, the incident, at best, precipitated a celebration of patient protection awareness and reiterated the need for vigilance, interprofessional, and non-forestall change on every bit of apparatus.

Assumptions

Analysis is grounded on a number of major assumptions. The conception that each one gifts healthcare professionals comprehends their role in ensuring patient protection. It was always assumed that the right communication, documentation, and verification procedures had never been used or were dormant. The second assumption is that the hospital employs tools such as incident reporting and will learn from near misses (Janssen et al., 2021). Both assumptions are that technology, in this instance, an eMAR machine, can reduce human errors effectively (Janssen et al., 2021). In the future, it was anticipated that the near-miss event would cause group behavior change, improve reputation, and improve the reporting system in the hospital.

Adverse Event with Root Cause Analysis

The near-miss incident in the town health center resulted from a scientific control mistake in the decision regarding the initial state of the wounded patient. The accident, as well as the misplaced prescription, had practically been recorded at the same time by virtue of lapses in checking or verification. Fundamental steps were skipped to the disadvantage of proper go-verifying of the prescription by the nurse. The last check before control was rushed or skipped. Serious regard among humans was no longer guaranteed. The injury was prevented by the intervention of the nurse. According to Mutair et al. (2021), the cause was a failure in the medication control process, i.e., deviation from protocol and possible insufficient training. The order could also no longer have been properly paired with the person’s record. The mistake could also have been avoided by interprofessional communication, such as a medication huddle or handoff. In a study, Kerari and Innab (2021) determined that if the eMAR tool had been employed, it would have, with high probability, detected the inconsistency. The accident used to be very preventable through proper tests, guidance, and equipment assistance. There needs to be beautiful teamwork and technology so that such dangers will not be repeated in the future.

Areas of Uncertainty and Knowledge Gaps

It has several areas of uncertainty as well as knowledge gaps about the town health center’s near-ignoring of the incidents. It is not always so that the process of breaking down medication takes place. We cannot even get an idea about how many personnel are trained on new procedures (Grailey et al., 2023). Nurs FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis is also unknown if communication equipment is used in medication administration. There could be a scarcity of data for the utilization or availability of devices that make up eMAR. It is also unclear if a double-glance perspective of the device is considered in an organized way by all the staff (Mutair et al., 2021). Those loopholes require more training, precise protocols, and proper methods of communication.

Evaluation of Quality Improvement Technologies

Town hospital has to adopt and sustain successful development practices of minimizing destiny medicine mistakes. The best generation that has the ability to enhance the safety of the patients is an eMAR device. Barcode medication scanning, firm ordering computerized (CFOE), and medical decision aid systems (CDSS) are also extremely important (Grailey et al., 2023). This generation provides the optimal drug that is administered to the patient. Today, generations can be denied complete utilization or integration. Employees can be forced to undergo additional training or retraining in the continuous utilization of such systems. Mandatory double-verifications, computerized alerts, and live boards are completed through several facilities in order to stop you from such errors (Grailey et al., 2023). The organizational policies can be discovered to enhance the following strategy for town medical facility leaders. Facility-diploma dashboards monitor information on error corrections, rate of incident reports, and response time of nurses. Dashboard information monitored 15 recent medication errors and 30 due dates in the other facility.

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

Additional reporting of near-misses could be an indication of additional caution on the part of staff or a breakdown in the system. Comparison of the information reported with national measures of protection would also reveal areas of improvement. Affected male or female satisfaction levels also can, by virtue of this, encompass patients’ sense of safety (Tariq & Scherbak, 2023). Internal factors must be monitored in the long term to select the improvements.

Affected patient pride and readmissions are also excellent measures. For example, the latest evaluation confirms that faulty pride in personality has increased by 10% within the last six months, even when readmission has decreased by 5% of patients (Bhati et al., 2023). Evaluating the data that are available from outside the organization and the data acquired from inside assists in comprehending areas that require more work and perform better quality. Enhancing the training of frames of workers and enlargement with dashboards could minimize the quantity of harm this is caused to the patients.

Criteria to Evaluate the Technologies

Improving the betterment of recreational activities and technology must be assessed against goal standards. In this regard, the success of such interventions should be measured in terms of fewer numbers in total medication errors and near misses (Tariq & Scherbak, 2023).

Second, usability levels and the degree to which utilized generation are present, and also eMAR, barcode scanning, and CPOE need to be calculated so that technology shouldn’t disrupt subjects’ speed or cause employees’ confusion. Further, information timeliness delivered by virtue of the generation is also an ideal focus to promote medical decision-making in affected character defense. The rate-benefit analysis is to be taken into account as well, i.e., the cost of investment in the technology versus offending sport and other benefits derived. Lastly, likely integration with great structures and education of employees for driving additional software success are fundamental issues (Reale et al., 2023). On this plan, with these factors, the city medical facility can establish what great development, sport, and technology can bring to the business enterprise, mitigate the factors of risk, and enhance the delivery of care services.

Quality Improvement Initiative

The case at the city clinic was once handled with the timely action of a keen nurse, preventing injury. However, it is exciting that such a phenomenon necessitates the need for thoughtful and planned monumental growth. Tariq and Scherbak (2023) depicted how the application of eMAR, barcode medication, and scanning via CPOE systems reduced medication errors to a phenomenal figure. While optimally applied, they ensure real-time affirmation that prescriptions are accurate and suitable for the patient. The said structures were effective by virtue of the lesser rate of undesirable sports by aversive mistakes by virtue of human mistakes and more appropriate discussion for most of the bulk of individuals (Ezike et al., 2023). Also, rehearsal of the typical bulk of individuals, simulation training walks, and behavior replication also enhance the rate of protection protocols. This feature of implementing a comments tool for near-miss in light of reports, assessments, and test-ups will allow the business organization to monitor its practice continuously (Vora et al., 2023). These evidence-based practices will put the clinic in a place where it can prevent future negative sports, improve patient protection, and build an organizational culture with a vision towards enhancing affected person protection.

Conflicting Data

For urban sanatoriums, aggregate evidence is, to a greater or lesser extent, in decreasing drug mistakes. According to the work done by Barakat and Franklin in 2020, it was discovered that the application of eMAR systems decreased medico-medicinal mistakes as a result of the improved system of documentation and real-time verification.

However, some of the previous studies have established that the adoption of eMAR machines is based on the adoption of the machine by the healthcare organization, staff training, and the use of the device (Vora et al., 2023). These variations determine that, even though there is potential for eMAR to ensure safety, the safety of the system also relies on the scope of its adoption and the adoption of the staff. In addition, some agencies reported device system failure, technical issues, or staff resistance, and this will somehow affect the functioning of such a generation (Tariq & Scherbak, 2023). Such contrary findings confirm that in embracing the generation, unusual variables such as training, manual, and embedding in the working environment must be taken into consideration in a bid to optimize affected person safety.

Conclusion

Generally, Nurs FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis close to eliminating cases in the town hospital confirmed that increased simplification of the huge improvement tools and eMAR equipment usage pining to lower the incidence of medicine mistakes and patient safety. However, research maintains the fact that the generation can be an invaluable gem in the way of protection if it’s miles managed professionally. The trouble zones need to be viewed as risk zones with communications and procedure differences.