Adverse Event or Near-Miss Analysis

Adverse Event or Near-Miss Analysis

In a healthcare setting that has a high-risk ratio, patient safety is the top priority; however, adverse events and near-misses are still persistent issues. These cases range from medication errors to communication problems, all of which can have huge consequences for the patient, the healthcare professional, and even the healthcare organization (Rodziewicz et al., 2023). As the nursing staff directly interacts with patients, they are on the frontline of identifying, managing, and near misses. This evaluation will delve into a near-miss incident at the intensive care unit (ICU) of Mercy Medical Center by exploring its implications, origins, and possible quality improvement measures. The case showed that an ICU patient nearly got an incorrect medication because of the laxity in medication safety measures. Exploring this case will help obtain knowledge related to the role of diverse elements in patient safety incidents and make plans for raising the level of quality and safety of care in ICU wards.

Although modern medicine and protocols have advanced greatly, the fact remains that medical incidents and close calls occur in healthcare settings, pointing out the unceasing need for vigilance and improvement efforts (Rodziewicz et al., 2023). The ICU is especially vulnerable to adverse medication events and medical errors because it primarily treats patients with more complex needs. One can point out the deep-rooted systemic problems and devise targeted measures to reduce the risks and improve the safety of the patients via the critical analysis of a brush with death in this setting. With this study, the hope is to advance the conversation on the topic of patient safety and quality improvement in healthcare, finally ending with better and safer patient care delivery for everyone.

Implications of Missed Events

The occurrence in Mercy Medical Center’s ICU has had far-reaching effects. Firstly, for the patient, it brought into focus the frailty of safety within the healthcare system. On the other hand, though the patient had been spared, it might have led to anxiety and brought down the patient’s trust in the medical team, as argued by Willis & Brady (2021). A nurse who experienced the near-miss situation realized they were just a close call away from failure if due care and attention were not being paid to medication administration. Through the ordeal, the nurse may have experienced stress and self-doubts, thus impacting his confidence and job satisfaction.

On top of this, the event had an impact on an entire healthcare team, promoting a culture of self-reflection and asking for a review of the current practices and communication techniques. Healthcare workers in all disciplines were reminded that integral to their work was the need for effective communication, standardized procedures, and a combined commitment to the safety of the patients. Janatolmakan and Khatony (2022) emphasize the need for ongoing training and quality improvement programs as a long-term strategy for preventing similar incidents in the future, and the hospital would fulfill its commitment to safe and high-quality care.

Analysis of Missed Steps

The root cause analysis of the ICU near-miss event in Mercy Medical Center determined that several missed steps and circumstances had contributed to the occurrence. For example, there is a lack of proper identification of patient allergies before medication administration, a questionable manifestation of the medication safety process. Moreover, the cognitive load was heavier than that of the standardized procedures and checklists during medication administration, which increased the risk of errors. The medication process was interrupted multiple times, which simply increased the risk of mistakes by distracting nurses and breaking their concentration. Furthermore, the communication line between the nurse and the other members of the healthcare team was not clear enough, resulting in poor teamwork and improper sharing of information. The omissions of these steps brought to light the inherent flaws of the medication safety practices and communication protocols inside the ICU unit, therefore calling for focused measures aimed at mitigating the risks and improving patient safety (Fair et al., 2023).

Evaluation of Quality Improvement Actions

To tackle this problem, Mercy Medical Center became involved in a multifaceted quality improvement endeavor designed to improve medication safety guidelines in the ICU. The initiative started with the creation and deployment of uniform medication administration processes, as well as the adoption of a barcode scanner technology in patient ID and medication verification. In addition, the hospital operated regular staff training programs about medication safety protocols and communication skills to achieve compliance with the best practices. Moreover, improved documentation practices were utilized along with effective communication networks among healthcare team members. A continuous monitoring and feedback mechanism was set up to check adherence to safety measures and find other areas that require further improvements, as indicated by Liukka et al. (2020). These focused interventions intended to reduce risks and improve patient care in the ICU enabled Mercy Medical Center to give patients safe and high-caliber care.

Integration of Solutions

In answer to the close call in Mercy Medical Center ICU, healthcare institutions have offered different solutions to prevent the reoccurrence of similar accidents and improve patient safety (Mutair et al., 2021). One of the most commonly used solutions is the use of barcode medication administration systems (BMAS). These systems use barcode technology to verify patient identity, medicine accuracy, and dosage, which lowers the probability of medication mistakes. Scanning barcodes on patients’ wristbands and medication labels will help nurses verify that the correct medication is given to the correct patient at the prescribed time.

On the other hand, healthcare organizations have focused on regularly training their staff on the dos and don’ts of medication safety protocols and communication techniques (Mutair et al., 2021). These workshops highlight the necessity of following the protocols, checking allergies twice, and keeping communication among the team members clear. By arming staff with the knowledge and skills they need, institutions enable them to safely and effectively operate in complex care environments and reduce the risks related to medication management.

On top of this, safety checklists for high-risk medications have been executed to create another safety net against mistakes. These checklists enumerate crucial steps for the medication process, including confirming the patient for any allergy, computing the accurate dosage, and documenting the administration details (Rodziewicz et al., 2023). By implementing standardized procedures outlined in safety checklists, healthcare professionals can reduce the probability of errors and ensure that the best practices are being adhered to uniformly.

Further, to improve patient safety in healthcare, interdisciplinary collaboration and communication have been made a priority. Healthcare institutions have adopted multiple strategies, such as structured handoff protocols and regular interdisciplinary rounds, to enhance the communication connections between the healthcare team (Mutair et al., 2021). Promoting a culture of teamwork and open communication enables clinicians in healthcare organizations to share important information as well as work collaboratively in patient care.

Relevant Metrics for Improvement

Quentin et al. (2019) argue that it is paramount to measure the effectiveness of the efforts in quality improvement to enable healthcare organizations to appraise their contribution to patient safety and care quality. As for the evaluation of medication safety and adverse event prevention initiatives, several relevant metrics can be applied. Firstly, healthcare institutions may find out how many medication-related near-miss events and adverse drug events (ADEs) have happened. The near-miss events are early warnings of opportunities for error in medication administration processes; therefore, they allow organizations to intervene preemptively and save patients from being harmed (Griffey et al., 2023). A thorough analysis of near-miss events will help institutions understand patterns, reasons, and directions for improvement in medication safety procedures.

Subsequently, the compliance rates of medication safety protocols and uniform procedures can be used as metrics for the efficiency of quality improvement projects. Organizations can evaluate the degree to which medical practitioners follow the institution of protocols like re-checking allergies, verifying medication doses, and accurately documenting administration details (Griffey et al., 2023). Compliance at a high level conveys a safety culture and adherence to best practices, but low compliance is indicative of training, communication, or process gaps.

Furthermore, employees’ perceptions about communication effectiveness and medication safety culture could provide critical information regarding quality improvement projects’ impact on the organizational culture and teamwork (Rodziewicz et al., 2023). Surveys or assessments done frequently can assess the views of medical personnel on communication media, team cohesion, and organizational dedication to patient safety. Accordingly, positive feedback indicates a culture of support and safety management. Negative feedback exhibits a plan for development in the areas of communication strategy or interdisciplinary collaboration.

Moreover, organizations can determine the effectiveness of quality improvement initiatives by measuring patient outcomes related to medication safety. Indicators like medication error rates, missed medication reconciliation, or patient satisfaction scores can be utilized to evaluate the impact of interventions on patient safety, clinical outcomes, or customer satisfaction (Ciapponi et al., 2021). Reduction of these indicators points to the improvement of medication safety protocols and quality care, which evidences the effectiveness of quality improvement initiatives.

Outline of Quality Improvement Initiative

To address the near-miss event and improve medication safety in the Mercy Medical Center intensive care unit, a comprehensive quality improvement initiative will be introduced. Under this initiative, the healthcare team will work on improving the medication administration processes, maintaining efficient communication among the healthcare team members, and creating a culture of safety and responsibility. This initiative will be based on the DMAIC (Define, Measure, Analyze, Improve, and Control) approach, a well-known approach for process improvement in healthcare environments (Monday, 2022).

In the Define phase, the main stakeholders will work together to identify the objectives of the project, such as the reduction of medication errors and near misses in the ICU. Baseline information will be obtained on medication errors, near-miss incidents, and adherence to medication safety protocols to set a standard. The Measure stage will use metrics like the rate of near-miss events, the rate of compliance with safety protocols, and the staff perception of communication effectiveness and safety culture as current medication safety state parameters for the ICU. Finally, the Analyze stage will involve a detailed root cause analysis of all medication errors and near-miss incidents to reveal system problems and potential solutions (Monday, 2022). Based on the outcome of the analysis, targeted interventions of standardized medication administration protocols, staff training on medication safety practices, and better communication strategies will be created in the Implementation phase. Lastly, in the Control phase, the monitoring and feedback mechanisms will be put in place to maintain improvements, ensure the implementation of safety protocols, and continuously evaluate the effectiveness of the initiatives aimed at reducing medication errors and enhancing patient safety in the ICU.

Conclusion

In conclusion, the quality improvement plan designed for Mercy Medical Center’s intensive care unit is an effective and systematic method for improving medication safety and preventing the occurrence of side effects. Utilizing the DMAIC methodology, the initiative will target the major aspects of the ICU, including medication administration practices, communication strategies, and safety culture, to reduce risks and improve patient safety and the level of patient care. Monitoring, feedback, and outcomes will be used to follow up the initiative; therefore, sustainable improvements and a culture for safety and accountability will be produced.

References

Ciapponi, A., Fernandez Nievas, S. E., Seijo, M., Rodríguez, M. B., Vietto, V., García-Perdomo, H. A., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Garcia-Elorrio, E. (2021). Reducing medication errors for adults in hospital settings. Cochrane Database of Systematic Reviews, 2021(11). https://doi.org/10.1002/14651858.cd009985.pub2

Fair, L., Burns, C., & Lindsley, J. (2023). Improving medication safety in an ICU. American Journal of Nursing, 123(7), 39–45. https://doi.org/10.1097/01.naj.0000944924.15137.c8

Griffey, R. T., Schneider, R. M., & Todorov, A. A. (2023). Near-miss events were detected using the emergency department trigger tool. Journal of Patient Safety, 19(2). https://doi.org/10.1097/pts.0000000000001092

Janatolmakan, M., & Khatony, A. (2022). Explaining the consequences of missed nursing care from the perspective of nurses: A qualitative descriptive study in Iran. BMC Nursing, 21(1). https://doi.org/10.1186/s12912-022-00839-9

Liukka, M., Steven, A., Vizcaya Moreno, M. F., Sara-aho, A. M., Khakurel, J., Pearson, P., Turunen, H., & Tella, S. (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

Monday, L. M. (2022). Define, Measure, Analyze, Improve, Control (DMAIC) Methodology as a roadmap in quality improvement. Global Journal on Quality and Safety in Healthcare, 5(2), 44–46. https://doi.org/10.36401/jqsh-22-x2

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improve reporting systems. Medicines, 8(9), 46. https://doi.org/10.3390/medicines8090046

Quentin, W., Partanen, V.-M., Brownwood, I., & Klazinga, N. (2019). Measuring healthcare quality. In www.ncbi.nlm.nih.gov. European Observatory on Health Systems and Policies. https://www.ncbi.nlm.nih.gov/books/NBK549260/

Rodziewicz, T. L., Hipskind, J. E., & Houseman, B. (2023, May 2). Medical error reduction and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/

Willis, E., & Brady, C. (2021). The impact of “missed nursing care” or “care not done” on adults in health care: A rapid review for the consensus development project. Nursing Open, 9(2). https://doi.org/10.1002/

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Assessment 1
Adverse Event or Near-Miss Analysis

Instructions
Resources
Activity 1
Activity 2
Activity 3
Attempt 1
available
Attempt 2
Attempt 3

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.

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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.

Adverse Event or Near-Miss Analysis

Overview
The goal of this assessment is to allow you to focus on a specific event in a healthcare setting that impacts patient safety and related organizational vulnerabilities and to propose a QI initiative to prevent future incidents. It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself in as a healthcare professional.

Healthcare 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. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation.

Historically, medical errors were reported and analyzed in hindsight. Today, QI initiatives attempt to be proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by new technologies and reporting metrics, adverse events, and near misses can provide insight into potential ways to improve care delivery and ensure patient safety.