Adverse Event or Near Miss Essay

Introduction

Adverse events are defined as events that occur due to unintended patient harm by an act of omission or commission (Freund et al., 2018). Adverse events range in terms of severity from minor, severe, to even death. One of the most common causes of adverse events is medication errors. medication errors occur at any point during patient care and this can range from medication prescription to administration. Nurses are major contributors to medication errors as they are mainly involved in medication administration. This paper will describe an adverse event that involved a medication error.

Analysis of the Adverse Event and the Missed Steps

The medication error involved the administration of the wrong medication to the patient. The patient, a 72-year-old woman presented with a medical history of hypertension. The patient was prescribed amlodipine (Norvasc) 10 mg, twice daily. Over the next 8 weeks, the patient reported constant fatigue, lethargy, slow movements, tremor, a ‘stoic’ facial expression, and personality changes. The assessment indicated that the patient’s hypertension was not optimally controlled. The patient was assessed and diagnosed with depression and anxiety and alprazolam and citalopram were prescribed. After 2 weeks, the patient presented to the emergency department after sustaining a fall due to poor ambulation and lightheadedness. She manifested blank facies, gait, and bradykinesia. The laboratory works indicate that the patient had elevated creatinine. Medication reconciliation indicated that the patient was taking thiothixene (Navane) 10 mg and not amlodipine (Norvasc). The review of the patient’s pill bottles indicated that Navane (an antipsychotic) was dispensed by the outpatient pharmacy, instead of Norvasc, and the patient was on this medication for more than 2 months. The written prescription was revealed to be legible. The patient was diagnosed with thiothixene-related drug-induced Parkinsonism.

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The adverse event (medication error that resulted in patient harm) was as a result of failures at multiple levels. The medication error first started at dispensing/transcribing that started as a pharmacy dispensation error, possibly due to a shortage of staff and constant pressure to fill timely prescriptions. There is a possibility that the outpatient pharmacy staff might have been understaffed, fatigued, and undertrained.

The medication error may also have occurred due to poor prescribing/monitoring. Multiple healthcare providers, including physicians and nurses, overlooked the patient’s usage of Navane for numerous weeks. The nurses who were examining the patient during clinic reviews did not review the patient’s medication regimen through pill bottle review. Additionally, the dose of Norvasc the patient was administered with exceeded the recommended daily maximum dose of 10 mg. On the other hand, Navane is associated with an elevated risk of death in older patients and thus should have been started at low doses of about 2 mg, followed by an upward titration. The patient was administered a dose of Navane 20 mg, which is the recommended dose for severe schizophrenia. The pharmacy staff and the nurses should have noticed the high starting dose and notified the prescribing physician. If this was done, the wrong medication may not have been administered. Additionally, a good therapeutic relationship between the pharmacy staff and prescribers would have avoided the medication error.

Implications of the Adverse Event for all Stakeholders

Medication errors are as a result of interactions from multiple factors, within a healthcare setting. An adverse event caused by medication errors that occurred to this patient impacts various stakeholders that include the patient, healthcare providers, the hospital, and other related agencies. For the patient, the medication error caused patient harm as manifested by the symptoms the patient exhibited and untreated hypertension. Additionally, the adverse event led to a prolonged treatment for the patient. Evidence indicates that medication errors are associated with increased morbidity and mortality; increased healthcare costs; and a prolonged period of hospital stay (Wondmieneh et al., 2020). Similarly, healthcare providers such as nurses, pharmacists, and physicians are impacted by medication errors in various ways. For example, evidence indicates that healthcare providers who commit a medication error that lead to an adverse event may experience emotional and psychological problems. Emotional distress can cause an increased risk of mental problems such as depression and burnout. Additionally, healthcare providers may end up in court battles and the risk of losing their jobs (Gracia et al., 2019). Healthcare organizations suffer significant impacts due to medication errors. Adverse events in hospitals are associated with increased healthcare costs due to prolonged hospitalization, reduced patient satisfaction, and low rating in the healthcare industry. Additionally, insurance companies rarely reimburse hospitalization due to medication errors and this leads to increased healthcare costs for hospitals (Gorgich et al., 2016). Other agencies that may be affected by medication errors include the Institute of Safe Medication Practices, Institute of Medicine (IOM), and insurance companies.

Quality Improvement Technologies

Quality improvement technologies such as automated dispensing cabinets, computerized physician order entry (CPOE), electronic medication reconciliation, and bedside bar-coded medication administration are some of the technologies that are effective in preventing medication errors, and the resulting adverse events (Vilela & Jericó, 2019). For this particular medication error, COPE, electronic medication reconciliation and pharmacy dispensing systems may have been useful in preventing the adverse event. The error started at the prescribing step where a higher dose was prescribed. CPOE is an effective intervention to improve patient safety. The CPOE ensures that the medication order is complete and legible; provides all drug information; checks for problems like allergies and drug-drug interactions; provides dose adjustment calculations; checks for suitable lab results; computes drug–laboratory interactions; and updates prescribers about the latest drug information (Wang et al., 2015).

Pharmacy dispensing systems would also be useful in preventing medication errors. Because pharmacies dispense high volumes of medications, dispensing errors such as in this patient’s case may occur. Therefore, a system such as an automated dispensing cabinet can decrease dispensing errors through automatic recognition, packaging, and dispensing using bar codes. Evidence indicates that bard-coding medications in pharmacies before dispensing medications to patients reduce dispensing errors significantly and also reduces the probability of adverse events occurring (Vilela & Jericó, 2019).

Relevant Metrics of the Adverse Event

According to Tariq et al (2020), approximately7,000 to 9,000 deaths occur due to medication errors. Many patients experience adverse reactions and other complications due to medication errors but do not report them. This indicates that the incidence of medication errors is very high. The common causes of medication errors consist of illegible handwriting, dosing errors, wrong drug selection, confusion due to similarly named drugs, and packaging errors (Tariq et al., 2020). Therefore, due to the adverse effects such as deaths and high morbidity, it is necessary to address medication errors and implement the appropriate measures to prevent medication errors and the consequent possible adverse events.

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Quality Improvement Initiative

The lack of adequate measures to prevent medication errors may be associated with an increased prevalence of medication errors.

An example of a quality improvement initiative that would be effective in preventing medication errors is performing effective staff training on the appropriate procedures to prevent medication errors (Naunton et al., 2016).  Therefore, the quality improvement initiative can include educating healthcare providers such as pharmacists and nurses about medication errors and the effective measures in preventing medication errors such as the use of electronic health records to verify patient information, computerized physician order entry (CPOE), electronic medication reconciliation, and bedside bar-coded medication administration. Additionally, the training will include educating healthcare providers regarding appropriate reporting of medication errors, different types of medication errors, and how to perform 10 rights of drug administration, before administering the medications (Izadpanah et al., 2018). Such a quality improvement initiative would go a long way in preventing medication errors in the organization.

Conclusion

The adverse event was about a medication error where a patient was administered the wrong medication and sustained patient harm. The medication error was as a result of a dispensing error and poor prescribing/monitoring. The adverse event had an impact on various stakeholders that include the patient, healthcare providers, the hospital, and other related agencies. Quality improvement technologies that can prevent the adverse event (medication error) include automated dispensing cabinets, computerized physician order entry (CPOE), electronic medication reconciliation, and bedside bar-coded medication administration. It is important to conduct an educative program to healthcare providers in the healthcare organization on how to prevent medication errors.

References

Freund, Y., Goulet, H., Leblanc, J., Bokobza, J., Ray, P., Maignan, M., … & Philippon, A. L. (2018). Effect of systematic physician cross-checking on reducing adverse events in the emergency department: the CHARMED cluster randomized trial. JAMA internal medicine, 178(6), 812-819.

Gorgich, E. A., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). 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), 54448. https://doi.org/10.5539/gjhs.v8n8p220

Gracia, J. E., Serrano, R. B., & Garrido, J. F. (2019). Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study. BMC health services research, 19(1), 1-9.

Izadpanah, F., Nikfar, S., Bakhshi Imcheh, F., Amini, M., & Zargaran, M. (2018). Assessment of Frequency and Causes of Medication Errors in Pediatrics and Emergency Wards of Teaching Hospitals Affiliated to Tehran University of Medical Sciences (24 Hospitals). Journal of medicine and life11(4), 299–305. https://doi.org/10.25122/jml-2018-0046.

Naunton, M., Nor, K., Bartholomaeus, A., Thomas, J., & Kosari, S. (2016). A case report of a medication error: In the eye of the beholder. Medicine95(28), e4186. https://doi.org/10.1097/MD.0000000000004186

Tariq, R. A., Vashisht, R., & Scherbak, Y. (2020). Medication errors. StatPearls [Internet].

Vilela, R., & Jericó, M. C. (2019). Implementing technologies to prevent medication errors at a high-complexity hospital: analysis of cost and results. Einstein (Sao Paulo, Brazil)17(4), eGS4621. https://doi.org/10.31744/einstein_journal/2019GS4621

Wang, H. F., Jin, J. F., Feng, X. Q., Huang, X., Zhu, L. L., Zhao, X. Y., & Zhou, Q. (2015). Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era. Therapeutics and clinical risk management11, 393–406. https://doi.org/10.2147/TCRM.S79238

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC nursing, 19(1), 4.

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Write a 5–7-page a comprehensive analysis on an adverse event or near miss from your professional nursing experience. Integrate research and data on the event and use as a basis to propose a quality improvement (QI) initiative in your current organization.

Health care 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.

 

The goal of this assessment is to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a quality improvement initiative to prevent future incidents.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.
    • Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
  • Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
    • 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.
    • Outline a quality improvement initiative to prevent a future 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 need for improvement.
  • Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
    • Communicate analysis and proposed initiative in a professional and 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 current APA style.

Suggested Resources

The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid.

Adverse Events and Reporting

These resources explore how cultures focused on safety learn from adverse events.

The following resources explore the benefits and challenges of incident reporting systems.

This resource examines organizational factors that lead to adverse events and near-miss incidents.

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Reporting Systems

These resources provide comprehensive event reporting systems data and performance assessment information:

This resource provides examples of adverse events and near-miss incidents:

Preparation

Prepare a comprehensive analysis on an adverse event or near-miss from your professional nursing experience that you or a peer experienced. Integrate research and data on the event and use as a basis to propose a Quality Improvement (QI) initiative in your current organization.

The numbered points below correspond to grading criteria in the scoring guide. The bullets below 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 that relate to each grading criterion.

  1. 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 that led to the event.
    • Discuss the extent to which the incident was preventable.
    • Research the impact of the same type of adverse event or near miss in other facilities.
  2. Analyze the implications of the adverse event or near miss for all stakeholders.
    • Evaluate both short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze how it was managed and who was involved.
    • Analyze the responsibilities and actions of the interprofessional team. Explain what measures should have been taken and identify the responsible parties or roles.
    • Describe any change to process or protocol implemented after the incident.
  3. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety.
    • Analyze the quality improvement technologies that were put in place to increase patient safety and prevent a repeat of similar events.
    • Determine whether the technologies are being utilized appropriately.
    • Explore how other institutions integrated solutions to prevent these types of events.
  4. Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement.
    • Identify the salient data that is associated with the adverse event or near miss that is generated from the facility’s dashboard. (By dashboard, we mean the data that is 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.
  5. Outline a quality improvement initiative to prevent a future adverse event or near miss.
    • Explain how the process or protocol is now managed and monitored in your facility.
    • Evaluate how other institutions addressed similar incidents or events.
    • Analyze QI initiatives developed to prevent similar incidents and explain why they are successful. Provide evidence of their success.
    • Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents.
  6. Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
  7. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

Submission Requirements

  • Length of submission: A minimum of five but no more than seven double-spaced, typed pages.
  • Number of references: Cite a minimum of three sources (no older than seven years, unless seminal work) of scholarly or professional evidence that support your evaluation, recommendations, and plans.
  • APA formatting: Resources and citations are formatted according to current APA style and formatting.

Adverse Event or Near Miss Analysis Scoring Guide grade

CRITERIA PROFICIENT DISTINGUISHED
Analyze the missed steps or protocol deviations related to an adverse event or near miss. Analyzes the missed steps or protocol deviations related to an adverse event or near miss. Analyzes the missed steps or protocol deviations related to an adverse event or near miss, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the analysis).
Analyze the implications of the adverse event or near miss for all stakeholders. Analyzes the implications of the adverse event or near miss for all stakeholders. Analyzes the implications of the adverse event or near miss for all stakeholders and identifies assumptions on which the analysis is based.
Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Evaluates quality improvement technologies related to the event that are required to reduce risk and increase patient safety. Evaluates quality improvement technologies related to the event that are required to reduce risk and increase patient safety and identifies criteria that can be used to evaluate the technologies.
Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement. Incorporates relevant metrics of the adverse event or near miss incident to support need for improvement. Incorporates relevant metrics of the adverse event or near miss incident to support need for improvement and evaluates the quality of the data.
Outline a quality improvement initiative to prevent a future adverse event or near miss. Outlines a quality improvement initiative to prevent a future adverse event or near miss. Outlines a quality improvement initiative to prevent a future adverse event or near miss, and impartially considers conflicting data and other perspectives.
Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling. Communicates analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling. Communicates analysis and proposed initiative in a professional and effective manner. Content is clear, logical, and persuasive; grammar, punctuation, and spelling are without errors.
Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style. Integrates relevant sources to support arguments, correctly formatting citations and references using current APA style. Integrates relevant sources to support assertions, correctly formatting citations and references using current APA style. Citations are free from all errors.

 

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