Assessment 1: Adverse Event or Near-Miss Analysis
Capella University Assessment 1: Adverse Event or Near-Miss Analysis-Step-By-Step Guide
This guide will demonstrate how to complete the Capella University Assessment 1: Adverse Event or Near-Miss Analysis assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for Assessment 1: Adverse Event or Near-Miss Analysis
Whether one passes or fails an academic assignment such as the Capella University Assessment 1: Adverse Event or Near-Miss Analysis depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for Assessment 1: Adverse Event or Near-Miss Analysis
The introduction for the Capella University Assessment 1: Adverse Event or Near-Miss Analysis is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
How to Write the Body for Assessment 1: Adverse Event or Near-Miss Analysis
After the introduction, move into the main part of the Assessment 1: Adverse Event or Near-Miss Analysis assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for Assessment 1: Adverse Event or Near-Miss Analysis
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for Assessment 1: Adverse Event or Near-Miss Analysis
The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.
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Assessment 1: Adverse Event or Near-Miss Analysis
An adverse event refers to an injury caused by medical interventions rather than the underlying condition. It prolongs hospitalization, causes a disability during discharge, or both. Preventable adverse events are injuries that occur owing to an error or failure to implement an established guideline for prevention (AHRQ, n.d.). A near miss event refers to a hazardous situation that is indiscernible from a preventable adverse event, excluding the outcome. The purpose of this paper is to comprehensively analyze a near-miss event that I experienced during my professional nursing practice.
Missed Steps or Protocol Deviations Related To an Adverse Event or Near Miss
As a new-grad nurse working on a medical-surgical floor, I experienced a near-miss event when I transfused the wrong blood to an anemic patient. The patient’s blood group was B+, and I administered AB+ packed red blood cells (PRBC). The floor had two patients requiring blood transfusion, and two PRBCs were delivered in the blood carrier box, one containing PRBC AB+ and the other B+ PRBC. Being a busy shift and we were short-staffed, I deviated from the hospital’s blood administration protocol that indicated that two qualified registered nurses must be present during a blood transfusion. The protocol also stated that each patient undergoing transfusion must be positively identified. The patient identifiers on the identification band must accurately match those on the blood component label. I deviated from the protocol, which led to administering ABO-incompatible PRBCs.
The blood administration error was identified approximately five minutes later when I was administering the other PRBC product to the second patient. When confirming the second patient’s name, blood product, and ABO compatibility, I realized that I had administered the wrong blood to the first patient. I immediately stopped the transfusion, took the vital signs, and informed the attending physician, who prescribed Hydrocortisone IV to prevent hypersensitivity reaction. Luckily, the patient did not experience any show signs of hypersensitivity. The incident was 100% preventable if I had followed the hospital’s blood administration guidelines, which state that the final check must be carried out next to the patient by two trained and competent healthcare providers who must also administer the component. Besides, if I had confirmed the right patient, blood product, and ABO compatibility in the patient with another nurse, the incident could not have occurred.
Blood administration errors have had an adverse impact on other facilities. Errors in identification (of patients, blood samples, and blood components) by health providers are the primary cause of most transfusion errors incidents, including ABO-incompatible transfusions (Ramsey, 2020). The incident results in severe acute transfusion reactions, which are the greatest cause of major morbidity in health facilities. Hospitals have also faced lawsuits from patients due to transfusion errors. However, the specific procedures that hospitals have taken to reduce such incidents are unknown, and information on this could enhance the analysis.
Implications of the Adverse Event or Near-Miss for All Stakeholders
The near-miss event has short- and long-term implications for stakeholders, including the patients, families, interprofessional team, and the organization. Short-term effects on patients include immunological reactions like hemolytic reactions, allergy/anaphylaxis, lung injury, circulatory overload, and bacterial contamination from blood components (Bolton‐Maggs & Watt, 2020). Long-term implications include renal failure and disseminated intravascular coagulation. The chances of mortality increase directly with the amount of incompatible blood transfused (Ramsey, 2020). Implications on the patient’s family include high healthcare costs used in managing the patient’s morbidities and the loss of loved ones. The interprofessional team risks losing their licenses if they are sued by the patient and found guilty of malpractice (Bolton‐Maggs & Watt, 2020). In addition, the risk of paying huge fines and even facing a jail term for professional negligence. The organization can face lawsuits from patients, which lead to huge fines and even closure on the grounds of professional negligence by employees.
Each interprofessional team member has a responsibility to create a culture of safety. The nurse supervisor is responsible for allocating duties equally and ensuring that crucial procedures such as blood transfusion are handled by the recommended number of staff. Nurses were responsible for ensuring that the nurse administering blood had an assistant to help confirm the patient, blood product, and ABO compatibility (Bolton‐Maggs & Watt, 2020). Physicians had the role of collaborating with nurses in blood transfusion procedures to promote patient safety. Following the incident, there was a change in protocol requiring that the nurse supervisor oversee every blood administration in their respective units to ensure the protocol is adhered to.
Quality Improvement Technologies Required To Reduce Risk and Increase Patient Safety
Healthcare technology can promote safety and efficiency improvements. Quality improvement (QI) technologies that enhance patient safety and prevent recurrence of blood administration errors include barcode technology and a bedside blood-tracking system. The bedside blood-tracking system uses handheld computers in the form of a personal digital assistant (PDA) (Hensley et al., 2019). The organization introduced the blood-tracking system as a safety measure to lower the risk of incompatible blood transfusions. It uses the PDA to scan the barcodes on a patient‘s wristband, the transfusion tag provided by the transfusion laboratory, and on the blood bag (Hensley et al., 2019). This ensures that the health provider positively identifies the patient. Health providers are also expected to identify themselves on the blood-tracking system by scanning barcodes on their staff identity badges.
The technologies are appropriate in preventing administration errors in patients receiving a blood transfusion. The barcode technology and PDAs increase blood administration safety by providing real-time patient information, transfusion profiles, laboratory values, and documentation, thus reducing errors (Hensley et al., 2019). Technology such as Bar-coding and handheld computers can be integrated into healthcare facilities to reduce the potential for transfusion errors and remove the need for two nurses to be involved in the blood checking procedure. Facilities can use single patient wristbands containing patient medical profiles, including allergies, thus minimizing potential incidents. The wristband can meet the positive patient identification requirements required in transfusion protocols, thus reducing risk and improving the safety of patients on transfusion (Hensley et al., 2019). Health facilities need to identify the bare minimum dataset for positive patient identification, which will be the basis for all clinical information systems. The dataset can be captured in two barcodes, having all the information needed to meet current and future conditions for secure patient identification (Hensley et al., 2019). The technologies can be evaluated by comparing the incidence of blood transfusion events caused by errors in patient identification before and after implementation.
Relevant Metrics of the Near-Miss Incident
Data from the facility’s dashboard reveal an average of three reported transfusion errors annually. The incident has significantly reduced from seven transfusion errors five years ago. One of the transfusion errors resulted in a lawsuit against the hospital, costing the organization $170000 as compensation to the patient. Transfusion errors are associated with prolonged patient stay and high healthcare costs. The metrics prove the need for the organization to improve the safety of patient care and eliminate the incidence of transfusion errors (Lancaster et al., 2021). The dashboard data is reliable since health providers are required to report every transfusion error, whether it results in an allergic reaction or not. About 21 million blood components are transfused in the U.S annually.1 The US Food and Drug Administration (FDA) is mandated to regulate the collection of blood donations and transfusion of blood components. According to the FDA, an average of 414 transfusion errors occur in the U.S. annually, which equates to one per 38,000 transfusions.
Quality Improvement Initiative to Prevent the Adverse Event or Near Miss
The facility now manages the blood transfusion process by ensuring positive patient identification, excellent communication, and documentation at every step of the blood administration process. The facility has adopted electronic transfusion management systems and barcode technology to enhance patient identification, communication, and documentation. Other institutions address the issue by mandating authorized documentation with minimum patient identifiers that must be verified against the label on the blood component (Lancaster et al., 2021). In addition, they provide the staff with hard copies of procedures for the infusion of blood products. They have created visual reminders in the inpatient units to remind the nurses of the blood transfusion procedures.
A barcode-based transfusion management (BCTM) system is a QI initiative established to prevent transfusion errors. It uses barcodes for identifying patients, onsite labeling, and verification of blood products via a wireless connection to the hospital information system (Hensley et al., 2019). The BTCM system is effective in reducing transfusion errors. Chou et al. (2019) found that BTCM lowered and sustained the near-miss rate to less than three incidents per quarter. The incidence of near-miss events reduced and stabilized at 0-1 per quarter for eight successive quarters from 2016 to 2017. Staff training programs can prevent future blood transfusion errors in our organization (Chou et al., 2019). Training can include face-to-face, simulation training, and competency assessments.
Conclusion
A patient is exposed to a dangerous situation in a near-miss event but does not face harm through early detection or luck. Near-miss vents are preventable if the set protocols are adhered to. Blood transfusion reactions have adverse health consequences for patients and put providers and facilities at risk of lawsuits. They can be prevented by adopting barcode technology and blood transfusion systems, which improve patient identification, communication, and documentation.
References
AHRQ. (n.d.). Adverse events, near misses, and errors. PSNet. https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
Bolton‐Maggs, P. H., & Watt, A. (2020). Transfusion errors—can they be eliminated?. British journal of hematology, 189(1), 9-20. https://doi.org/10.1111/bjh.16256
Chou, S. S., Chen, Y. J., Shen, Y. T., Yen, H. F., & Kuo, S. C. (2019). Implementation and Effectiveness of a Bar Code–Based Transfusion Management System for Transfusion Safety in a Tertiary Hospital: Retrospective Quality Improvement Study. JMIR medical informatics, 7(3), e14192.
Hensley, N. B., Koch, C. G., Pronovost, P. J., Mershon, B. H., Boyd, J., Franklin, S., … & Stierer, T. L. (2019). Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. The Joint Commission Journal on Quality and Patient Safety, 45(3), 190-198. https://doi.org/10.1016/j.jcjq.2018.08.010
Lancaster, E. A., Rhodus, E. K., Duke, M. B., & Harris, A. M. (2021). Blood Transfusion Errors within a Health System: A Review of Root Cause Analyses. https://doi.org/10.33940/med/2021.6.6
Ramsey, G. (2020). Landsteinerʼs legacy: The continuing challenge to make transfusions safe. Transfusion, 60(12), 2772-2779. https://doi.org/10.1111/trf.16205
Health care organizations and providers have a legal, ethical, and professional mandate of guaranteeing patient safety at all times. Before actual practice, health care providers usually learn the basics of patient safety, strategies for enhancing safety, and implications of unsafe practices. Despite the safety emphasis, adverse and near-miss events often occur in health practice. Medical errors are among the main events, the third cause of deaths and up to 1.1% of hospital admissions in the United States (Schwendimann, 2018). Due to the profound impacts of such events, including permanent injuries and death, it is vital for health care organizations to adopt the necessary intervention strategies to enhance patient safety. This paper analyzes an adverse event related to medication errors and evaluates its implications on stakeholders and quality improvement technologies for increasing patient safety.
Background Information: The Incident
At a neonatal intensive care unit (ICU) at Neo Care Medical Center, the pediatrician nurse reported that a premature baby’s blood glucose level was down at 17. The situation was not expected since the baby was under Total Parenteral Nutrition (TPN) infusion for over six hours. Multiple bolus doses of dextrose and infusion followed, including a sodium chloride mix, but the hypoglycemia did not change until nurses decided to discontinue TPN. To examine the real cause of the situation since they failed to bring the sugar level up to save the baby, the neonatologist requested the TPN analysis. The infusion contained insulin instead of heparin.
Analysis of the Missed Steps Related to the Adverse Event
ICUs are high-risk operation areas where a small error can cause death. According to Eltaybani et al. (2019), complex care processes such as premature births, advanced health care technologies, and quick therapeutic responses usually complicate processes at ICUs such that the level of medication error is high. To a huge extent, the speed of the operation can trigger an error. However, failure to give the correct infusion was the main cause of the heparin-insulin confusion that led to the baby’s death. At all times, health care providers are advised to do everything possible to prevent adverse events related to medication errors, and this case is a suitable explanation of the severity of the situation.
Several medical management issues led to the medication error. Overdose, labeling problems, and improper drug storage jointlyexacerbated the adverse outcomes in this scenario. In many instances, insulin is taken at 3-4 hour intervals for diabetic patients (Acosta, 2020). Insulin usually comes in a 10 ml vial. Heparin intake is after 8 hours. Like insulin, heparin was also dosed in the care facility at 10 ml little bottles. Both are high-risk medications but were not kept away from each other. The dispensing nurse was also new in the facility, implying that the possibility of confusing the two drugs was very high. Besides the similarity in dosage, heparin and insulin were both stored in an orange and white vial with an orange top. Syringes used for their dosing were also of similar sizes stored in close shelves too.
As the case illustrates, the nurse missed the right steps in drug confirmation by quickly assuming that she was giving a dose of heparin. She was used to giving heparin stored in the exact quantities and storage containers. The adverse outcome could have been prevented if there were a system process or protocols compelling nurses to confirm the drug before administering it to any patient. Nurses should also be consulting each other when operating in high-risk areas such as in the ICUs. Close monitoring of the patient is highly recommended, unlike in this scenario where nurses waited for six hours to monitor the progress and act.
Similar incidents in other facilities are also common. Acosta (2020) reported that insulin-heparin confusion often occurs due to the similarities in vials, specialized syringes, and administration units. Indeed, the probability of risk is high when heparin and insulin are placed together. Skochelak (2020) further mentioned that heparin dosage instead of insulin usually causes an overdose since the patient is prompted to take heparin at an interval of four hours instead of the usual eight. Treating a patient wrongly using heparin has been a leading cause of bleeding in many patients and damage in the subcutaneous tissue around the stomach. The impacts are profound and costly to patient and families.
Implications on Stakeholders
Adverse events have huge implications on stakeholders, and the stakeholder team needs to play its role effectively to avoid adverse consequences. In case of a permanent injury, the quality of patients’ lives usually gets affected to the extent of remaining unproductive for the rest of life. As a premature baby, there is nothing the baby could have done in this scenario. The family is affected by dependence and costly litigations when a patient’s life is ruined due to a medication error. The interprofessional team was partly to blame in this scenario. The level of coordination did not match the expected standards putting the baby at risk. Such adverse outcomes affect a facility’s reputation, and the level of the community’s trust in the facility is affected too.
Health care providers working in high-risk departments should always work as a team. The level of interprofessional collaboration should be high, with each interprofessional team member playing individual roles expertly. To create a culture of safety in the facility, nurses were supposed to consult each other before administering the drug. The pharmacist should have helped to reconfirm the drug and the right dose. Health care administrators should have enhanced storage mechanisms to keep look-alike drugs away from each other. Moreover, the IT department should have installed proper drug confirmation systems to eliminate the possibility of errors associated with manual confirmation.
When an adverse event occurs, health care facilities should put the right interventions in place to prevent a similar incident. Barakat and Franklin (2020) recommended that change in protocols and the implementation of new technologies usually reduce medication errors. After the incident, a change of protocol happened since new neo-natal nurses were required to undergo in-service training to make them conversant with the place and drug storage procedures. Labeling was also improved by increasing the font size and using legible style and visible stickers.
Quality Improvement Technologies
Health technologies play an instrumental role in preventing medication errors. One of the suitable technologies to avoid such incidents in this facility is barcode systems to ensure proper procedures. According to Barakat and Franklin (2020), barcode scanning systems improve correctness regarding dosage verification, particular medication, delivery route, timing, and the patient. Such systems also eliminate over-reliance on paperwork by providing on-screen alerts based on patient needs and type of drugs. Besides barcodes, storage in digitized refrigerators is vital to maintain efficacy. A nurse should first electronically search where a particular drug is stored to avoid any confusion in such situations. The same case applied to Neo Care Medical Center. Proper labeling supplemented by barcode scanning can minimize the probability of errors by a huge margin.
Dashboard Metrics for Neo Care Medical Center
Health care organizations usually operate to meet some specific benchmarks. Some benchmarks are internal, and others external. Dashboard metrics are reliable reference points of the key areas that an organization should enhance performance to achieve the required care quality. Some of the relevant metrics in Neo Care Medical Center include a rate of up to 15% of medication errors. The rate of reporting is as low as 3%. Deaths from medical errors stand at 7%, and permanent injuries at 10%. The other relevant data includes waiting time in the emergency department with an average of one hour. Compared to external data, a lot of improvement is crucial in Neo Care Medical Center to achieve the desired outcomes. According to Wondmieneh et al. (2020), a medication error rate of above 5% indicates that a health facility has systemic problems. Other data that CDC and AHRQ provide include the average waiting time in emergency departments, which should be below forty minutes. As a result, Neo Care Medical Center should be keen on its underperformance areas and use interprofessional and technological approaches to improve outcomes.
Quality Improvement Initiative to Prevent the Recurrence of the Adverse Event
Like in Neo Care Medical Center, digitized storage and labeling are vital in reducing medication errors. In-service training is also an outcome-based procedure to improve outcomes that health care facilities should consider. For better outcomes, health care institutions should consider the integral role of documentation and computerized provider order entry. When paired with clinical decision support systems, computerized provider order entry prevents prescribing and transcribing errors (Patient Safety Network, 2019). Other interventions useful to the facility and other health care settings include using clinical pharmacists to oversee all medication dispensing processes and keeping high-risk medications such as insulin and heparin in automated dispensing cabinets. Neo Care Medical Center should consider such storage mechanisms to improve current performance and perform as state and national benchmarks obligate.
In conclusion, adverse events have far-reaching consequences on the patient, family, health care providers, and organizations. They affect all the stakeholders involved in the care process. Like the case of Neo Care Medical Center, such errors can stem from improper labeling, protocol hitches, and storage problems. To enhance patient safety, technology can be useful; barcode scanning is highly recommended and automating of storage procedures is also necessary. Interprofessional teams should also work closely and report when an error occurs to improve interventions.
References
Acosta, W. R. (2020). Study guide for pharmacology for health professionals. Jones & Bartlett Publishers.
Barakat, S., & Franklin, B. D. (2020). An evaluation of the impact of barcode patient and medication scanning on nursing workflow at a UK teaching hospital. Pharmacy, 8(3), 148. http://dx.doi.org/10.3390/pharmacy8030148
Eltaybani, S., Mohamed, N., & Abdelwareth, M. (2019). Nature of nursing errors and their contributing factors in intensive care units. Nursing in Critical Care, 24(1), 47-54. https://doi.org/10.1111/nicc.12350
Patient Safety Network. (2019, Sep). Medication errors and adverse drug events. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
Schwendimann, R., Blatter, C., Dhaini, S., Simon, M., & Ausserhofer, D. (2018). The occurrence, types, consequences and preventability of in-hospital adverse events–a scoping review. BMC Health Services Research, 18(1), 1-13. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3335-z
Skochelak, S. E. (2020). Health systems science. Elsevier.
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), 1-9. https://doi.org/10.1186/s12912-020-0397-0