Adverse Event or Near-Miss Analysis

Adverse Event or Near-Miss Analysis

Medical errors are increasingly becoming implicated in the deterioration of care outcomes in caregiving facilities. These errors are multifaceted, with the majority attributable to the healthcare providers themselves. Nurses, being a component of healthcare provision, are not an exception. Nursing-related medical errors have been reported and remain a major contributing factor in poor patient prognosis and avoidable mortalities. These instances have seen an upward trend despite technological advances in healthcare that aim to enhance and maintain safety in the healthcare system. Therefore, detailing an adverse event related to nursing practice that I have experienced in my nursing practice is essential.

A 65-year-old female attending chemotherapy sessions presented for her routine chemotherapy. The chemotherapeutic agent in use on this patient was cisplatin. Administration of anti-cancer chemotherapy follows protocols that are specific to each agent. The patient developed sudden onset nausea and consequent vomiting. The vomiting was severe and blood-stained. Within ten minutes, the patient fell unconscious and was transferred to the ED, where she was stabilized and later discharged.

Analysis of Missed Steps Related to the Adverse Event

The administration protocol required that intravenous premedication with an antiemetic agent and proton pump inhibitors and adequate hydration be given to prevent the immediate side effects of cisplatin. In this instance, the nursing team failed to administer the required dose of the proton pump inhibitor as directed and also failed to administer the antiemetic drug. This medical error resulted in severe adverse events in the patient that prompted the stopping of the drug. Cisplatin is a highly emetogenic drug. Its use has been implicated in breakthrough vomiting and nausea (Oun et al., 2018). Premedication with proton pump inhibitors and antiemetic drugs dramatically reduces the occurrence of these events. For this reason, the administration protocol for cisplatin directs the use of pre and post-chemotherapy administration of antiemetic agents and proton pump inhibitors. Accordingly, the nursing team was required to follow these guidelines to ensure that these events did not occur.

Pre-chemotherapy medications remain necessary to prevent adverse events caused by various chemotherapy agents. Nurses maintain a central role in the administration of these medications. Research in cancer treatment and treatment outcomes suggests that the immediate adverse events of most chemotherapy agents usually experienced at the bedside are attributable to nurse-related medical errors (Gorgich et al., 2017). These errors include the admission of inaccurate doses, omission of one or more agents, or failure to adhere to treatment protocols of specific drugs.

Implications of the Adverse Event on Stakeholders

As much as nurses are involved in the execution of a majority of medical orders, they are not the only ones required to ensure patient safety within the healthcare system. Healthcare provision is a multidisciplinary field that draws various health professionals as well as other stakeholders. Additionally, these stakeholders include the patient themselves, their care providers, the care facility, the patient’s families, and their community. All these stakeholders work in concert to ensure safe and optimal care outcomes in patients. Subsequently, nursing-related adverse events have short- and long-term effects on all of these stakeholders.

In the short term, adverse events such as the one described above may have deleterious effects on the patient. Severe cases often warrant hospital admission and increased treatment costs due to the management requirements of the particular event. Adverse events may also warrant discontinuation of very effective drugs, leaving little or no treatment choices to manage their suffering. On the other hand, the long-term effect is often felt in a generally increased treatment burden on the patient, their families, and their communities.

Healthcare providers maintain a central role in the prevention of provider-related adverse events. Their sole responsibility is to ensure optimal care outcomes most safely. The nurses and the pharmacists should work in concert to ensure that accurate doses and drugs are used in patient management. Medical doctors and laboratory specialists should also work in concert to ensure an accurate diagnosis of diseases. Any lapse in these responsibilities often leads to medical errors that may be devastating to the patient. In this case, the nurses and the pharmacists should have ensured the availability of all medications required for premedication. The nurses were also required to follow the guidelines to prevent this adverse event.

Quality Improvement Technologies

After the incident, the hospital management instituted several measures that ensured better communication between the nurses and the pharmacists. The nursing team was also educated on the guidelines for various chemotherapeutic agents and how the common side effects could be identified and managed. The hospital also issued a requirement for all healthcare professionals in the oncology healthcare team to be present during the entire chemotherapy sessions.

Various technological advances in healthcare have been instituted to ensure patient safety and improve patient outcomes. In this case, the instituted technologies targeted at enhancing communication within the healthcare team and others enhanced information availability to the healthcare providers. In this regard, medical guidelines for specific drugs were outlined and posted to the nurse’s desk. An electronic health records system was also incorporated in the oncology clinic to ensure the free flow of information among the healthcare team (Bjarnadottir & Lucero, 2018). The software was also established to provide information on various chemotherapeutic agents. The nurses were also encouraged to use the software frequently and attend occasional online training on patient handling at the oncology clinic.

The technologies rolled out in response to the adverse event were appropriate and necessary. This is because of their ability to adequately address nursing difficulties that have been implicated in medical errors. The electronic health records system is essential in healthcare communications (Tyagi et al., 2017). Informative software is also crucial in educating nurses on the appropriate interventions to take on specific presented cases. Several pieces of research reinforce the significance of healthcare technologies in enhancing the safety and outcomes of patients. Electronic health records, clinical decision systems, and computerized physician order entry are some of these technologies that enhance the safety of patients.

Relevant Metrics of Quality Improvement

Adverse events occurring at the point of care of the oncology clinic of the healthcare facility in question have been adequately documented over time. The information generated from the facility’s dashboard reveals that the common on-session adverse events include nausea, vomiting, fatigue, and bleeding. These side effects are specific to various chemotherapeutic agents. The findings also reveal that provider-related medical errors are attributable to over 50% of the cases. Adverse events have been implicated in significant patient suffering. Research findings also reveal that these events are caused in part by medical-related errors. Nurses account for most of these medical errors due to their higher interactions with the patients (Liukka et al., 2020). Various healthcare agencies have developed metrics targeted at addressing specific aspects of safety and quality enhancement. WHO is such an agency whose metrics have seen widespread use in various healthcare settings (Zhou et al., 2017). Specific aspects of the WHO metrics that could be adopted in this hospital include accidental puncture rates, the incidence of events, and the rarity or unexpectedness of these events.

Quality Improvement Initiatives

In the wake of increasing medical errors leading to adverse events, the facility came up with several strategies to improve the quality and safety of care. Through the pharmacy team, the hospital made a review on all the chemotherapeutic agents utilized in the clinic. Specific protocols were then established and then communicated to all the nurses. Nurses are required to undertake any nursing operation as provided in the protocols. They are also required to occasionally attend continuous medical training on patient handling at the oncology clinic.

Continuous medical training for nurses has provided an important tool to update their knowledge. This strategy has ensured the safety of many patients across various facilities. This initiative has also ensured the reduction in nurse-related medical errors. Other initiatives that have been used in this course include the institution of healthcare technologies such as electronic healthcare records.

To conclude, nurse-related medical errors have been an attributing factor to the occurrence of various adverse events. Increasing interprofessional communication may be necessary to prevent these cases. Interprofessional communication enables crucial information in patient handling and drug administration. Consequently, this information may enhance their patient-handling capabilities and their knowledge of drug administration requirements.

 References

Bjarnadottir, R., & Lucero, R. (2018). What Can We Learn about Fall Risk Factors from EHR Nursing Notes? A Text Mining Study. Gems (Generating Evidence & Methods to Improve Patient Outcomes), 6(1), 21. https://doi.org/10.5334/egems.237

Gorgich, E., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2017). Investigating the Causes of Medication Errors and Strategies to Prevention of Them from Nurses and Nursing Student Viewpoint. Global Journal of Health Science, 8(8), 220. https://doi.org/10.5539/gjhs.v8n8p220

Liukka, M., Steven, A., Vizcaya Moreno, M., Sara-aho, A., Khakurel, J., & Pearson, P. et al. (2020). Action after Adverse Events in Healthcare: An Integrative Literature Review. International Journal of Environmental Research and Public Health, 17(13), 4717. https://doi.org/10.3390/ijerph17134717

Oun, R., Moussa, Y., & White, N. (2018). The side effects of platinum-based chemotherapy drugs: a review for chemists. Dalton Transactions, 47(19), 6645-6653. https://doi.org/10.1039/c8dt00838h

Tyagi, R., Cook, L., Olson, J., & Belohlav, J. (2017). Healthcare technologies, quality improvement programs, and hospital organizational culture in Canadian hospitals. BMC Health Services Research, 13(1). https://doi.org/10.1186/1472-6963-13-413

Zhou, Y., Ke, C., Jiang, Q., Shahin, S., & Snapinn, S. (2017). Choosing Appropriate Metrics to Evaluate Adverse Events in Safety Evaluation. Therapeutic Innovation & Regulatory Science, 49(3), 398-404. https://doi.org/10.1177/2168479014565470

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Assessment 1 Instructions: Adverse Event or Near-Miss Analysis
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Write a comprehensive analysis (4 pages) of an adverse event or near miss from your nursing experience. Integrate research and data on the event to propose a quality improvement (QI) initiative to your current organization.

Adverse Event or Near-Miss Analysis

Introduction
Healthcare 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.

This assessment’s goal is to address a specific event in a healthcare setting that impacts patient safety and related organizational vulnerabilities with a quality improvement initiative to prevent future incidents.

Instructions
For this assessment, you will prepare a comprehensive analysis of an adverse event or near miss that you or a peer experienced during your professional nursing career. You will integrate research and data on the event and use this information as the basis for a quality improvement (QI) initiative proposal in your current organization.

The following points correspond to the grading criteria in the scoring guide. The sub-bullets under each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your adverse event or near-miss analysis addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels relating to each grading criterion.

Analyze the missed steps or protocol deviations related to an adverse event or near miss.
Describe how the event resulted from a patient’s medical management rather than from the underlying condition.
Identify and evaluate the missed steps or protocol deviations leading to the event.
Explain the extent to which the incident was preventable.
Research the impact of the same type of adverse event or near miss in other facilities.
Analyze the implications of the adverse event or near miss for all stakeholders.
Evaluate the short- and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze each stakeholder’s contribution to the event.
Analyze the interprofessional team’s responsibilities and actions. Explain what measures each interprofessional team member should have taken to create a culture of safety.
Describe any change to the process or protocol implemented after the incident.
Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
Analyze the quality improvement technologies put in place to increase patient safety and prevent the recurrence of near misses or adverse events.
Determine the appropriateness of the technology application for a specific patient or situation.
Research scholarly, evidence-based literature to learn how institutions can integrate solutions to prevent similar events.
Incorporate relevant metrics of the adverse event or near-miss incident to support the need for improvement.
Identify the salient data associated with the adverse event or near miss that is generated from the facility’s dashboard.
Note: Dashboard means data generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management.
Analyze what the relevant metrics show.
Explain research or data related to the adverse event or near miss that is available outside of your institution. Compare internal data to external data. Use resources such as the Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Institute for Healthcare Improvement (IHI), and the World Health Organization (WHO).
Outline a quality improvement initiative to prevent the recurrence of an adverse event or near miss.
Explain, from an evidence-based viewpoint, how your facility now manages or should manage the process or protocol.
Evaluate how other institutions addressed similar incidents or events.
Analyze QI initiatives developed to prevent similar incidents. Explain why they are successful. Provide evidence of their success.
Propose solutions for your selected institution that can be implemented to prevent similar future adverse events or near-miss incidents.
Communicate analysis and proposed initiative in a professional, 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 APA style.
Example Assessment: You may use the Adverse Event or Near-Miss Analysis Exemplar [PDF] for an idea of what an assessment receiving a proficient or higher evaluation would look like. &

Additional Requirements
Submission length: 4 typed, double-spaced pages.
Font: Times New Roman, 12 points.
Number of references: Cite a minimum of five current scholarly and/or authoritative sources to support your evaluation, recommendations, and plans. Current literature is defined as no older than 5 years unless it is a seminal work.
APA formatting: Citations and references must adhere to APA style and formatting guidelines. Consult these resources for an APA refresher:
Evidence and APA.
APA Module.
American Psychological Association. (n.d.). APA style. https://www.apastyle.org/
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 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.
Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
Outline an evidence-based quality improvement initiative to prevent an 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 the need for improvement.
Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
Communicate analysis and proposed initiative in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling.
Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.