Prepare an analysis (5–7 pages) of an adverse event or a near miss from your professional nursing experience and outline a QI initiative that would address it.
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] Download Guiding Questions: Adverse Event or Near Miss Analysis [DOCX]document for additional clarification about things to consider when creating your assessment.
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.
- APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APAsection of the Writing Center for guidance.
Title: Analysis of an Adverse Event in Nursing Practice and a Quality Improvement Initiative
Introduction
Nursing practice is inherently complex, and despite the dedication and competence of healthcare professionals, adverse events and near misses can occur. In this essay, I will analyze an adverse event that occurred during my professional nursing experience and outline a Quality Improvement (QI) initiative to prevent future occurrences. The adverse event involved a medication error, which had significant implications for all stakeholders. Through a root cause analysis, I will delve into the sequence of events and protocol deviations related to the incident, evaluate QI actions and technologies, and propose a comprehensive QI initiative.
Adverse Event Analysis
The adverse event involved a medication administration error in which the wrong medication was administered to a patient. The patient received a medication meant for another patient with a similar name. Fortunately, the error was detected before any harm occurred, classifying it as a near miss. However, the incident had implications for various stakeholders, including the patient, nursing staff, healthcare institution, and regulatory authorities.
- Implications for Stakeholders:
a. Patient: While the patient did not suffer harm, they experienced anxiety and distress upon learning of the medication error. This incident eroded the patient’s trust in the healthcare system.
b. Nursing Staff: The nursing staff directly involved in the error faced emotional distress, guilt, and the fear of professional consequences. It also created a sense of insecurity and self-doubt among the team members.
c. Healthcare Institution: The institution faced potential reputational damage, increased legal liabilities, and regulatory scrutiny. It highlighted weaknesses in the medication administration process and the need for immediate action.
d. Regulatory Authorities: The incident prompted regulatory authorities to investigate the institution’s medication safety practices and compliance with established guidelines.
- Root Cause Analysis:
To understand the sequence of events leading to the medication error, a root cause analysis was conducted. The analysis revealed several contributing factors:
a. Communication breakdown: Inadequate communication among healthcare providers and staff contributed to the error. The healthcare team did not effectively cross-verify patient identities and medication orders.
b. Medication labeling: Similar medication packaging and labeling contributed to confusion. The packaging of the medications lacked distinctive features, making it easier to confuse them.
c. Fatigue and workload: Nursing staff members were fatigued due to high patient loads and extended working hours. Fatigue reduced their cognitive abilities and attention to detail.
d. Lack of standardization: There was no standardized process for medication administration, leading to inconsistencies in practice.
QI Initiative Outline
To prevent future adverse events or near misses related to medication errors, a comprehensive QI initiative is proposed:
- Standardization of Medication Administration:
Implement standardized procedures for medication administration, including patient identification protocols, medication labeling, and verification processes. This will reduce the risk of errors stemming from confusion and communication breakdowns.
- Medication Barcoding Technology:
Introduce barcode scanning technology for medication administration. This technology will ensure that the right medication is administered to the right patient by matching barcodes on the medication, patient wristbands, and medication orders.
- Workload Management:
Address staff workload issues by optimizing staffing levels and shift schedules. Implement strategies to reduce nurse fatigue and burnout, such as regular breaks and limiting overtime.
- Continuous Education and Training:
Provide ongoing education and training to nursing staff on medication safety, error prevention, and effective communication. Promote a culture of continuous learning and improvement.
- Reporting and Analysis:
Establish a robust incident reporting system and encourage a culture of transparency. Regularly analyze reported near misses and adverse events to identify trends and areas for improvement.
- Collaboration with Pharmacy:
Enhance collaboration between nursing and pharmacy departments to review medication processes and packaging, ensuring clarity and differentiation between similar medications.
- Patient Engagement:
Involve patients in their care by encouraging them to verify their medications and ask questions about their treatment. Empowering patients as active participants in their healthcare can serve as an additional safety check.
Conclusion
Adverse events and near misses in nursing practice have far-reaching implications for all stakeholders. Root cause analysis is essential to identify contributing factors and develop effective QI initiatives. In the case of the medication error near miss discussed here, a comprehensive QI initiative involving standardization, technology, workload management, education, collaboration, and patient engagement can significantly reduce the risk of future incidents. It is crucial for healthcare institutions to embrace a culture of continuous improvement to enhance patient safety and the quality of care provided.