Capella University NURS-FPX6016: Quality Improvement of Interprofessional Care Instructor’s Name October 2024
Adverse Event or Near Miss Analysis
Healthcare organizations are responsible for implementing strategies in the clinical setting that will help the staff members generate positive patient outcomes by providing quality treatment to the patients and remaining upgraded with the recent inventions in the medical industry for the sustainability of the quality improvement initiatives (Bhati et al., 2023). However, adverse or near events often occur in clinical practice for various reasons, including staff shortening and overburdening, ineffective technological use, and medication errors. The adverse events may cause long-lasting health damage while near-miss events ensure the prevention of health disparity at the edge of the damaging situation. These health-damaging events not only impact the patient but also greatly affect the practice of the staff members and the reputation of the healthcare organization. Through the root cause analysis, the practice gaps can be effectively identified and improved using technological interventions and quality improvement initiatives.Near Miss Event Scenario
In a Vila Health Care facility, a patient was prescribed intravenous antibiotics with a certain schedule. The medical history of the patient was considered and it was observed that the patient had allergies to certain antibiotics which made it necessary to keep precautionary measures while injecting IV antibiotics into the patient. Due to specific issues the incorrect medications were administered which was identified by the second round checking nurse thus preventing a large scale of health damage that can lead to adverse health outcomes. The incorrect administration of the medicine occurs due to a lack of identification and consideration of known allergies of the patients recorded at the time of patient admission to the clinical setting. However, with the intervention of an alarm system of Electronic Health Records (EHR), it can be possible to timely respond to proper allergies identify medications to prevent health damage, and ensure the safety of the patient.Implications of Adverse Events on Stakeholders
The adverse events will have serious implications on the stakeholders especially patients as they are ensuring their life safety in the hands of the healthcare professionals for effective health treatment (Skelly et al., 2023). The near-miss event regarding the wrong medicine administration is prevented but it affects the credibility of the healthcare organization in providing quality treatment to the patient without compromising patient health and safety. These errors can directly impact the well-being and satisfaction of the patient with the treatment provided to them thus creating a negative healthcare environment. The nursing staff will also be greatly affected by the near-miss event as it will question their knowledge and practice including the leanings of the patients. Moreover, the staff can lose their competency in the clinical setting thus largely affecting their medical career. The healthcare organization will also lose its reputation thus creating a lot of issues involving financial problems, staff shortening, staff training costs, the intervention of healthcare technologies, and so on. The pharmacies also need to double-check the medication prescribed in the paint treatment plan for the prevention of health disparities (Tariq & Scherbak, 2024). The near-miss events also affect the regulatory agencies as they focus on providing quality care to the patients and ensuring their safety of the patient by providing timely effective treatment and proper medicines necessary to improve patient health. The patient family will suffer greatly from the implications of near-miss events as they are closely related to the patient care coordination process.Assumptions Identification
The clinical setting focuses on the assumption that the environment of the healthcare is positive without any blame game practices in which the staff members will honestly report about the near miss event for the improvement in the current system. Another assumption is the extra dependency of the healthcare providers on the technological healthcare information systems for the validation of quality treatment. It has also been assumed that the communication between the staff members and the healthcare provider is fast and smooth thus generating positive patient outcomes. Moreover, there is a complete focus on patient-centered care for all the stakeholders along with the assumption that near-miss events are the opportunity for the healthcare providers to effectively learn and prevent health damage.Root Cause Analysis of Near Miss Event
Sequence of Events
The patient was admitted to the hospital with a health issue determined by the allergy to the cephalosporins as recorded in the EHR to keep the patient’s medical history safe and easily accessible at the time of treatment. The patient was prescribed IV antibiotics after a specific time. The healthcare physician suggested cephalosporin to the patient with no knowledge regarding the alley of the patient thus not focusing on the EHR system for the history of the patient. The pharmacist approved the medicine without even cross-checking the EHR of the patient and prescribed medicine due to the workload regarding the delivery of other medicine orders. The physician and pharmacist both were unaware of the patient’s allergy due to no alarm system in the EHR regarding the wrong medication identification and prevention (Bui & Preuss, 2023). The antibiotic was delivered to the nurse on duty who didn’t even check the EHR for the identification of the near-miss events regarding the allergy of the patient. However, just before administering the antibiotic, the nurse went through the random check which showed the allergenic sign of the patient with the physician’s suggested antibiotic.Missed Steps
The missed steps are the major factor that leads to the occurrence of missed events in the clinical setting. It is the responsibility of healthcare practitioners to ensure that all the protocols regarding the provision of treatment to the patients are followed to ensure a positive health response to the patient along with enhanced satisfaction. A few identified missed steps are listed below;- The EHR is not upgraded to generate alerts for the wrong medication about the prevention of health damage at the first step.
- The nurse didn’t use the scanning process through the barcoding technology which also resulted in a near miss event.
- Ineffectivity of the pharmacist regarding the cross-check of the medication by matching it with the prescription.
- Lack of communication between the staff members and the other healthcare stakeholders regarding the identification of allergy status with the suggested medicine.