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Write a 5–7-page comprehensive analysis on an adverse event or near miss from your professional nursing experience. Integrate research and data on the event and propose a quality improvement (QI) initiative in your current organization. The purpose is to assess whether specific quality indicators demonstrate improvements in patient safety, quality of care, cost, and efficiency. Target audience includes nurses and health professionals interested in the condition or issue. Your analysis should include: an examination of missed steps or protocol deviations, assessment of preventability, impact on stakeholders, management and involved personnel, changes made post-incident, quality improvement technologies, relevant metrics, external research data, and a proposed QI initiative with examples from other institutions. Ensure your work is clearly written, supported by at least three scholarly sources published within the last seven years, and formatted according to current APA standards.

Paper For Above instruction

The occurrence of adverse events and near misses in healthcare settings poses significant challenges to the delivery of safe and effective patient care. These incidents, often stemming from system-based errors, protocol deviations, or human factors, necessitate thorough analysis to develop effective quality improvement strategies. This paper examines a specific adverse event from my professional nursing practice, integrating research and institutional data to understand its implications and to propose targeted interventions aimed at enhancing patient safety and care quality.

Case Description and Analysis of Missed Steps

The selected adverse event involved a medication administration error where a patient received an incorrect dose of anticoagulant therapy, leading to a minor bleeding episode. The event resulted from a combination of protocol deviations, including nurse omission of double-check procedures and inadequate communication during shift change. The analysis reveals that the failure to follow established medication administration protocols was a primary contributor. Research shows that medication errors are among the most common adverse events in hospitals, often preventable when proper protocols are adhered to (Kohn, Corrigan, & Donaldson, 2000). In this case, the error was tied to human factors such as fatigue and workload, which compromised vigilance and adherence to safety checks.

The incident was primarily a result of systemic issues rather than patient-specific factors. Protocol deviations included bypassing the "two-person check" policy, due to staff shortages and time constraints. Such omitted steps are significant because they serve as critical safeguards against errors. Literature emphasizes that failure to perform these redundancies significantly increases the risk of medication errors (Tang et al., 2016). The preventability of this adverse event was high; adherence to established protocols would likely have avoided the error.

Impact on Stakeholders and Management of the Event

The immediate stakeholders impacted included the patient, who experienced bleeding, and the nursing staff responsible for medication administration. Additionally, the healthcare facility suffered potential reputational damage and increased risk of litigation. Long-term effects could include decreased patient trust, staff burnout, and increased scrutiny on medication safety practices.

The event was initially managed through prompt recognition of bleeding, discontinuation of anticoagulant therapy, and monitoring of the patient’s hemodynamic status. The interprofessional team quickly coordinated to provide appropriate clinical interventions, including transfusions if necessary. The responsibilities extended across nursing, pharmacy, and medical staff, emphasizing the importance of teamwork and communication in managing adverse events. Post-incident, a root cause analysis was conducted, leading to a reevaluation of current protocols.

Protocols, Changes, and Quality Improvement Technologies

Following the adverse event, the organization implemented several changes, including mandatory double-check protocols for high-risk medications, enhanced staff training, and utilization of barcode medication administration (BCMA) technology. The BCMA system integrates scanning procedures that verify medication, dose, and patient identity, reducing human error (Poon et al., 2010). These technologies are designed to trigger alerts when discrepancies arise, thereby functioning as real-time safeguards.

Effectiveness of these interventions was monitored through facility dashboards, which track medication errors, near misses, and adherence to safety protocols. Metrics such as error rates before and after device implementation indicated a significant reduction in medication errors (Lee et al., 2019). External data from the Institute for Safe Medication Practices also supports the effectiveness of barcode systems in enhancing medication safety, aligning with internal findings (ISMP, 2022).

External Data and Comparative Analysis

Research outside the organization corroborates the internal data. Studies show that healthcare facilities employing barcode verification systems experience a 50-70% reduction in medication errors (Poon et al., 2010; Naik et al., 2015). Comparing internal metrics with national benchmarks highlights the organization's progress post-implementation, yet also indicates ongoing opportunities for improvement through staff education and process refinement.

Additionally, institutions that adopted a culture of safety emphasized continuous quality monitoring, staff engagement, and transparent incident reporting. These practices foster an environment where errors are openly discussed and addressed, supporting ongoing learning and improvement (Wilson & Joinson, 2011). The positive outcomes illustrate the importance of integrating technology with robust safety culture principles.

Proposed Quality Improvement Initiative

Building on existing measures, a comprehensive QI initiative is proposed, aimed at further reducing medication errors and near misses. The initiative involves three core elements: continued staff training emphasizing protocol adherence, integration of advanced medication verification technologies, and fostering a safety culture that encourages open communication about errors.

Implementation would include simulation-based training to reinforce safety steps, further automation of medication dispensing and verification, and routine audits of error data to identify trends. The initiative's success would be measured through ongoing monitoring of error rates, staff compliance, and patient safety metrics in the dashboard.

Furthermore, the organization can look to peer institutions that effectively reduced errors through multidisciplinary safety huddles and real-time feedback mechanisms (Fitzgerald et al., 2019). These strategies promote proactive problem-solving and build resilience within the nursing and healthcare team.

Conclusion

Adverse events, such as medication errors, underscore the importance of systemic safeguards, technology, and a culture of safety in healthcare organizations. The analysis highlights that adherence to protocols, reinforced by technological solutions like barcode verification, significantly reduces error likelihood. To prevent similar incidents, a dedicated QI initiative incorporating staff training, technological integration, and safety culture development is essential. Continuous evaluation, data-driven decision-making, and interprofessional collaboration remain critical to advancing patient safety and quality of care.

References

• Fitzgerald, G., et al. (2019). Multidisciplinary safety huddles: An effective strategy for reducing errors. Journal of Patient Safety, 15(2), 89-95.
• Institute for Safe Medication Practices (ISMP). (2022). Medication safety in healthcare systems. https://www.ismp.org/
• Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To err is human: Building a safer health system. National Academies Press.
• Lee, S. H., et al. (2019). Impact of barcode medication administration systems on error reduction: A systematic review. Journal of Healthcare Quality, 41(5), 227-235.
• Naik, P. K., et al. (2015). Effectiveness of barcode medication administration in reducing errors. International Journal for Quality in Health Care, 27(4), 287-294.
• Poon, E. G., et al. (2010). Effect of barcode technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707.
• Tang, J., et al. (2016). Human factors in medication administration errors. Journal of Nursing Scholarship, 48(2), 126-134.
• Wilson, S., & Joinson, C. (2011). Cultivating a safety culture in nursing. Journal of Nursing Management, 19(3), 367-375.