NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

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NURS FPX 6016 Assessment 1 

Adverse Event or Near-Miss Analysis

Student Name

Capella University

NURS-FPX-6016

Professor Name

Submission Date

Adverse Event or Near-Miss Analysis

Despite the advances in technologies, standards of safety, and interprofessional training, adverse incidents and near misses in healthcare remain unchanged. Adverse drug event (ADE) is medical damage caused by a drug which may be potential or actual. Near misses are potential ADEs that may result in damage but actually did not do it (Nouri et al., 2024). A close call of look-alike medication vials in an emergency is examined in this paper in terms of its outcomes to the stakeholders, the time sequence of the incident, and the etiology. Plans to improve quality improvement (QI) based on evidence-based practice are then identified to improve patient safety and preventive measures.

Scenario

The one of the near misses was in a high acuity behavioral health unit in a psychiatric emergent requiring physical restraints and an immediate intramuscular (IM) medication. The midazolam was mistakenly selected by the charge nurse during the stress because of the similarity of the color of the caps and bottles of the vials. One of the second nurses observed the mistake and avoided the potential harm to the patient even before the injection was performed. The fact that this incidence was a non-injurious event still exhibited grave flaws in the system. Since the system uses visual cues, there are fewer chances of barcode verification and the system lacks the normal protective strategies, including color labeling or organized groupings of medicines.

Implications for Stakeholders

To the patient, the risks of the near miss were acute such as over-sedation, lack of enough symptoms suppression in the case of the wrong medication, or respiratory depression. Even when there is no physical injury, the relatives are likely to lose trust in the quality of a given facility and develop a high level of fear about the safety of the person in question, which affects the confidence in behavioral health services. Emotional stress, self-doubt, and fear of punishment were also subjected to the interprofessional team, and these factors are likely to reduce the levels of morale and job satisfaction. Griffey et al. (2023) define near misses as intercepted medical errors and events that require an action to avoid harm, which implies that even non-harmful events have an impact on learning and the safety of the system. At an organizational level, the problem of accreditation, quality actions, and liability has been raised in the incident, and the need to protect against the issues has been mentioned as preserving the form of medicine storage and increasing verification and verification measures.

Responsibilities, Corrective Actions, and Assumptions

Here, the major nurse is about to administer the intramuscular medication without making checks. The second nurse prevented the error by indicating the wrong vial and reporting the near miss. The attending psychiatrist reviewed medication orders to make sure that the medication order was in accordance with the treatment plan, and the pharmacist was the one to label and separate look-alike vials so as not to confuse them. The corrective actions that were to follow this incident were to fill in a formal incident report, to report the pharmacy leadership on the similarity of packaging and to temporarily relocate the medicines to reduce the chances of confusion. The members of the staff in this analysis can be considered competent and well-trained that were constrained by the chaos of the psychiatric emergency that limited their possibilities to act in accordance with the requirements of normal safety. Furthermore, more advanced controls such as color coded labeling or segregated medication trays were not implemented in the unit resulting in increased human vigilance dependency. Nouri et al. (2024) highlighted the importance of developing a culture of safety and open culture of communication in which the healthcare professionals will feel free to report the near misses to them without fear of consequences. Such a practice will assist in establishing transparency, reducing stigmatization around reporting and also proactive learning at a system-wide level which will contribute to the safety culture.

Sequence of Events and Medical Management

The near miss incident involved a psychiatric emergency of physical restraining and immediate intramuscular (IM) medication. The mistake did not arise due to the disease, but rather due to the processes of dealing with the drugs in the event of emergency. The charge nurse was under pressure and he had to use midazolam, as the vials were almost similar in packaging and the color of the cap. The failure to perform barcode scanning and an independent check-up are some of the protocol violations that resulted in the event, as these are practices that are never done when there is an emergency. The information on preventable adverse events (PAE) and near misses is reported with the assistance of different monitoring strategies, and their complementary information is delivered (Isaksson et al., 2021). These are activities such as frequent inspection of records, incident reporting procedures and safety briefings whose quality would prove that risks are not identified when patchy safety measures are taken. Active measures such as integrating routine safety briefing with routine reviews will provide the teams with the opportunity to identify system failures at an early stage and to share experience in real-time. Isaacsson et al. (2021) believe that the combination of these strategies improves learning within the organization and reduces the likelihood of repeat mistakes, which is why they are an effective place to start with long-term patient safety changes. Besides, the hospital administrators had not adopted major measures like color-coded trays and had to rely on speedy visual inspection that is especially susceptible to errors during stress-inducing situations.

Interprofessional Communication and Preventability

Better interprofessional interaction would have been useful in mitigating the risk. Though the second nurse escaped without any injury, organizational solutions such as a read-back or to verification of the drug would have helped identify the error in good time. The close call could have been prevented by emphasizing the fact that nurses should be more aware of reconciling orders, label checks, and documentation of administration and reducing the number of interruptions (Manias et al,. 2020). Without formal communication procedures, the errors will be subject to personal surveillance in case of acute behavioral health crisis.

Knowledge Gaps and Areas of Uncertainty

Through the root cause analysis, certain findings have been made yet there are still a number of gaps that limit in-depth knowledge of the incident. It is not mentioned that staffs were subjected to a simulation based medication administration training in restraints training, fatigue or understaffing and environmental disturbances. Secondly, it is not clear that barcode scanning could technically be carried out in the restraining zone, which can be considered as a measure of systemic barriers to the compliance with protocols. As Nouri et al. (2024) stressed the importance of the fact that the establishment of the culture of safety and open communication wherein the report about the near miss is not seen as a part of the punishment scheme but, on the contrary, as the way to learn and to make sure that such an incident never occurs again. This environment promotes transparency, organizational learning and strengthens systemic improvements that improve patient safety in the long-term.

Quality Improvement Actions and Technologies

It requires a number of quality improvement (QI) technologies and practices that can help to reduce the threat of medication errors in case of a behavioral health emergency. The systems of barcode medication administration (BCMA) are necessary because they significantly reduce the errors connected with patient misidentification and the administration of the wrong dose, improving point-of-care verification (Zheng et al., 2020). Similarly, computerized physician order entry (CPOE) systems address the problem of transcription errors because the orders are entered electronically and are filled in. Electronic health records (EHRs) and CPOE are the technological innovations that demonstrated the possibility to minimize errors yet they only succeed when introduced with appropriate caution and training of personnel (Anjum et al., 2024). Controlled substances monitoring and the minimization of medication selection errors with added safety and automated dispensing cabinets (ADCs) can still lead to an emergence of new types of errors, although the inappropriate design or lack of education can still lead to them (Zheng et al., 2020). Along with technological solutions, design-based interventions are necessary as well. As one such example, color-coded compartmentalized trays were shown to facilitate lower cognitive load and accuracy processing under stress (Laxton et al., 2023), whereas team training in simulation conditioned more verification behaviour and improved confidence to prevent errors among staff. In order to ensure that such interventions are working, the evaluation criteria should include adherence to scanning procedures, error of interception, and staff confidence.

Integration of Solutions in Other Institutions

In another case, other institutions have used technology to assist in the elimination of drug errors in the emergency through redesigning workflow. The approach of using compartmentalized tray design in visual search where standardized color codes are used was found to be effective to reduce the effects of cognitive load, and overall performs better in comparison with the traditional tray designs (Laxton et al., 2023). Similarly, centres that have properly structured verification approaches such as team read-back or verbal confirmation mechanisms have asserted to have improved interprofessional communication (Mallette, 2021). One of the analyses revealed that with the implementation of automated dispensing cabinets and barcode systems in mental and emergency departments, medication safety can be improved, yet to implement such a system entirely is essential to follow all the steps (Zheng et al., 2020). Findings confirm technological protective measures reinforce the safety measures.

Metrics and Dashboard Data

The most widespread indicators which are observed through the institutional dashboards are the rate of medication errors, near-misses, staff performance to follow the verification process, and an overall patient safety rate. The metrics that can be used in the near-miss situation include the number of restraint-related medication errors, the rate at which any medication has been scanned prior to administration and the trend in the reported safety events. The monitoring data on dashboard revealed that barcode scanning compliance in the case of an emergency situation was low, and a current tendency of errors associated with look-alike vials. Manias et al. (2020) article asserted that the 58% medication errors (MEs) of psychiatric inpatients is at a high risk of causing harm. Internal data can be compared with these external trends to help the facilities make decisions on their performance.

Comparative Data and Implications

Similar findings are also made by external metrics, which point to the fact that look-alike and sound-alike drugs are among the most frequent reasons behind near misses in care. The system-level measures that can be used to minimise these risks are identified as dose error-reduction technology, standardized labelling, and workflow redesign by the Institute for Safe Medication Practices (ISMP, 2020). The gaps in patient safety are who-tracked when the internal data demonstrates a high reliance on human and staff attention, with no effective technological and design-based security. Moreover, two powerful types of tracked high-trace trays and the usage of color-coded labels can help to reduce the rate of medication errors (Laxton et al., 2023). These external standards are matched against the performance of the facilities internally to identify the areas of weakness, invest in workable strategies, and instill a safety culture within the behavioral health.

Quality Improvement Initiative

It was the alertness of the second nurse in the selected institution that spotted the near miss and reported through the safety reporting mechanism. The only form of monitoring behavioral health medication workflow was incidence reporting. One example is that the standardized color-coded compartmentalized trays have been reported to be more efficient in visual search, less in cognitive load, and medication compared to traditional tray designs (Laxton et al., 2023). The implementation of barcode medication administration (BCMA), especially when used in conjunction with CPOE and ADCs, will lead to the reduction in the number of visual checks and minimization of the number of avoidable adverse drug events (Zheng et al., 2020). Simulation training ensures the enhancement of communication and verification practice, and the specified aspect offers the guarantee that the safety of safeguards is applicable even during the emergency (Mallette, 2021). These efforts can be effective in implementing safety in the work processes as opposed to placing the staff under security during the period they are under pressure.

Elements for Future Prevention

Such approaches as design-based approach, technological approach, and education should also be included in a sustainable QI program. The key points of the change are restructuring emergency medication trays with color coded, the introduction of compulsory check-ups or read-backs every time it is an emergency dealing with a psychiatric crisis and simulation training, which is conducted quarterly and improves the teamwork. BCMA and ADC implemented in behavioral health units, such as restraint events, may provide additional safety levels in case it is adjusted to the particular setting (Zheng et al., 2020). The indicators of success are error rates, the adherence to the scanning and the verification procedures, and the trends of safety events reporting.

Considering Conflicting Perspectives

Although the evidence offered about these interventions is supportive, there exist counter arguments that should be examined. Badly implemented, BCMA leads to disrupted workflow, high workload, and medication errors (Mulac et al., 2021). Smaller facilities also lack the financial or resource bases to implement the sophisticated technology such as BCMA or ADCs. However, the necessity to apply certain best practices of medication safety, such as separating high-alert medications and their effective distinctions, was emphasized by other institutions, including ISMP (ISMP, 2020). The focus on efficiency and the need to focus on the patient safety would ensure that the proposed QI program would be realistic and sustainable.

Conclusion

The almost similar case of the resemblance medication vials during a behavioural crisis in healthcare demonstrates the immediate significance of the system-wide safety within the high-stress care setting. Although it did not cause any harm, the incident helps to identify weaknesses that are dangerous to the patients, families, staff, and the organization. According to the root cause analysis, the color-coded labelling, simulation training, and barcode verification are the necessary interventions that allow reducing the risk and increasing the safety. The culture of safety can be strengthened with an organized program of quality improvement, which will increase the reliability and prevent such similar near misses in the future.