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

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

Student Name

Capella University

NURS-FPX 6016 Quality Improvement of Inter-professional Care

Prof. Name


Adverse Event or Near-Miss Incident Analysis

Hospitals commonly encounter various adverse events every day. These events can be near-miss or actual events that may have negative impacts on the patients, the hospital’s workforce as well as on hospital’s reputation. The study defines adverse events as those preventable incidences due to medical treatment or because of the actions of healthcare professionals, which causes unfavorable outcomes for patients’ safety (Liukka et al., 2020) further study describes near-miss events as those incidents which have not caused the harm yet because of any preventive intervention taken already before the harmful action could happen (Lee, 2021).

The prevalence of adverse events in healthcare settings approximately ranges from 2.9% to 16.6%, out of these the preventable errors range from 1.0% to 8.6% (Zanetti et al., 2021). There is research conducted to analyze that adverse events can be life-threatening as well. It is estimated that above 250,000 patients encounter adverse events out of which 100,000 face mortality (Skelly et al., 2022). There are several kinds of adverse events that occur in healthcare settings. The purpose of this analysis report is to discuss adverse drug events (ADE) of a case that happened in the Adult Medical Unit at Vila Health Facility. Moreover, some of the strategies will be presented to eradicate these events. 

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

Mrs. John, a 75-year-old female patient is admitted to the hospital because of Acute Gastroenteritis. She is in the ward for the last two days and is receiving regular treatment. Yesterday, nurse Helen was assigned to the patient. She had a very busy shift because of low staffing and she was assigned 10 patients at a time. During her shift, Mrs. John complaint of epigastric pain and feeling nauseated. Helen immediately informed the doctor about the patient’s complaint and probed to prescribe any medication. Doctor Gen entered the medication in the system and asked the nurse to give Metoclopramide 10mg to the patient from the stock cabinet until the drug arrives at the pharmacy.

Helen being understaffed and overworked took out Metoprolol instead of Metoclopramide from the stock cupboard and without carefully checking the label, she administered the medication to the patient. After 30 minutes, Mrs. John’s caretaker rushed to the nursing counter and shouted that her patient is feeling dizzy and had an irregular breathing pattern. Upon arriving at the patient’s room, the nursing team and doctors found that the patient is unconscious and her vital signs are deranged. Immediate code blue was announced.

All healthcare professionals tried their best to save the patient but she ended up losing her life. Nurse Helen was called by the nursing supervisor to investigate the issue. Moreover, the patient’s family was informed about this undesirable event which led them to file legal cases against the nursing staff as well as the hospital. This was a challenging event that provoked nurses and the hospital administration to further examine adverse drug events in their hospital setting to ensure patient safety and quality improvement (QI). 

Implications for the Stakeholders

Every issue that a healthcare facility faces requires a team of multi-professional personnel and various stakeholders to plan, derive solutions, make decisions, support financially, and implement those solutions to ensure patients’ safety and quality improvement. In this case, Mrs. John and her family are the foremost stakeholders which were negatively impacted by this adverse event. In the second line, the affected stakeholder is the nurse who was involved in this adverse event and lastly, the hospital and hospital’s administration, and directors are involved. 

Negative patient outcomes have various implications for healthcare providers, hospital administration, and policymakers. It is the primary responsibility of doctors and nurses to provide quality care to their patients using standardized clinical practices, especially regarding medication safety. On the other hand, nurse leaders should ensure that every team member is fully equipped with the best-practice knowledge of medication safety. Moreover, administration and policymakers are required to establish policies for medication safety ensuring patients’ safety is not compromised (Abdulrouf et al., 2019). Various assumptions on which this analysis is based are

  • An increasing number of errors/adverse events lead to mental stress among healthcare professionals eventually causing more complications for patients as well as for the health workforce. 
  • Adverse events and errors are part of the healthcare system but it is essential for stakeholders to effectively collaborate to alleviate such events from the healthcare systems and improve quality of life (Laird et al., 2020). 

Therefore, it is significant for hospitals like Vila Health facility to take appropriate measures to reduce these adverse events. For this purpose, some of the actions and technologies will be discussed later in this analysis. 

Missed Steps, Protocol Deviations, and Knowledge Gaps Analysis

The case presented above gives evidence that negligence related to medication administration can lead to severe complications for patients. A study showed that the prevalence of ADE ranges from 16.3% to 18.3% per 100 patients. Furthermore, these adverse drug events can cause many significant harms to the patient with 1.4% of life-threatening harm and a mortality rate is 8.8% to 9.5% cases out of 100,000 patients (Sahilu et al., 2020). This evidence reveals the importance of preventing drug-related errors in hospitals to preserve patients’ safety and improve care. Some of the missed steps and protocol deviations identified in this situation are:

  1. Following verbal orders is strictly inappropriate in healthcare settings except in the code blue situation. The nurse should avoid following the verbal order given by the doctor to prevent any discrepancies in medication prescription and administration. 
  2. The five rights of medication administration were not followed by the nurse. The nurse must be aware of the right patient, the right drug, the right dose, the right route, and the right time. Deviating from any one of the rights can lead to severe medication errors and adverse outcomes. 
  3. The nurse should inform their team leader in case of short staffing to avoid performing such actions which may impair patients’ safety. Nurse leaders should develop policies and protocols so that effective care is provided without harming patients’ safety. 
NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

To ensure patient safety in terms of preventing adverse drug events, a framework is established which is called rights of medication. Research recognizes that because of nurses’ non-adherence to the rights of medication, 32.6% of drug-related errors are due to incorrect administration of drugs (Salami et al., 2019). These five “R” (rights) are the right patient, the right drug, the right dose, the right time, and the right route (Jones & Treiber, 2018). Nurses must be equipped with the knowledge and appropriate implementation of this framework. Nursing leaders are expected to promote the concept and the administration should develop policies against these malpractices. 

In this case, if there is some missing information like Metoclopramide is a basic medication then why Helen couldn’t wait for the pharmacy to dispense the drug? Why the doctor was not aware of the policy of verbal orders? Why the short-staffed unit was not supervised by the team leader? What role did the hospital administration play in this circumstance? The availability of these pieces of information would have led to a complete and well-organized adverse event analysis. 

Quality Improvement Strategies and Technologies

The literature recommends various actions to improve the quality of care and ensure patients’ safety, especially in terms of medication safety. One of these actions is promoting the Quality and Safety Education of Nurses (QSEN, 2020). QSEN competencies are established to reduce the risk of harm to patients as well as to healthcare providers by improving the system’s effectiveness along with enhancing individual performance. These competencies are based on six categories: 

Patient-centered careTeamwork and collaboration
Evidence-based practicesQuality improvement 
Safety Informatics 

It is recommended that nurses are continuously educated keeping in mind these safety competencies in the context of improving medication safety so that standardized practices are followed (Watanabe et al., 2021). The education curriculum should focus on the rights of the medication framework discussed earlier, international practices of medication administration, and patient safety protocols of the hospital. Another quality improvement action recommended by the literature is the avoidance of verbal orders. The study mentions that verbal orders should be avoided as much as possible and can only be an issue in specific circumstances or example emergency/crash situations. Every hospital should develop this policy of verbal orders to ensure safety (Ambwani et al., 2019).

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

The policy of “repeat-back” and “read-back” verification. According to the policy, the order-receiving person will repeat the verbal order back to the ordering doctor in a way that it is clear and the dose is separately repeated for example 30 should be said as “three zero”. Furthermore, the recipient has to mention the date, and time and sign the order and it is the responsibility of the prescriber to counter-sign it within 24 hours. Advanced research related to quality improvement (QI) is focused on decreasing human errors by introducing various technologies. One such technology to reduce ADE and improve medication safety is the bar-coded medication administration (BCMA) system. BCMA assists nurses in correctly identifying patients as well as drugs.

The bar-coded system is a technology based on the rights of medication and prevents human errors by following this framework. This system also enables hospitals to follow Joint Commission International Accreditation (JCIA) standards of patient safety (Rodziewicz et al., 2022).  A comprehensive study identified that the initiation of barcoding technology for medication administration resulted in a 41% of reduction in these errors and a 51% decrease in the possible ADEs (Küng et al., 2021). Another technology is the use of Radiofrequency Identification (RFID) tags. These tags can trace all information related to a product, in this context the correct identification of the patient and the drug can reduce the cases of adverse events (Profetto et al., 2022). 

Along with the implementation of the strategies, it is essential to evaluate the success. Vila Health facility should utilize measurement systems to perform the evaluation 

  • Pre and post-intervention incidences of medication errors and ADE (Barakat & Franklin, 2020). 
  • Cost reduction due to the implementation of strategies
  • Nursing competence scale for medication safety (Yang et al., 2021). 

Quality Improvement Initiative 

The QI improvement initiative for the Vila Health facility should be implemented and measured using the PDSA model (plan-do-study-act). This method is a continuous cycle that enables healthcare facilities to implement any intervention and evaluate its effectiveness simultaneously (Knudsen et al., 2019). The Agency for Healthcare Research and Quality (AHRQ), states that the PDSA cycle is the easiest way to evaluate a change that is implemented in clinical settings. The Vila Health facility can utilize this methodology:

PLAN: Establishing a team, recognizing organization resources, and identification of the most vulnerable department for adverse drug events (ADEs). 

DO: Implementation of the strategies at a small-scale (vulnerable department). 

STUDY: Evaluate the success using evaluation metrics.

ACT: Implement on the hospital level. 


Improvement of care quality and patient safety can be challenging for healthcare facilities, especially in terms of medication safety. Hospitals need to improve their medication safety by improvising their workforce’s knowledge and education as well as establishing policies to eradicate these adverse events from the hospital. Quality improvement initiatives, such as the following QSEN competencies, staff education, policies of a verbal order, and installation of a barcode system as well as radiofrequency identification tags will assist in reducing these errors. Moreover, effective collaboration and teamwork are also essential to improve patient safety and quality improvement. 


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Ambwani, S., Misra, A. K., & Kumar, R. (2019). Medication errors: Is it the hidden part of the submerged iceberg in our health-care system? International Journal of Applied and Basic Medical Research9(3), 135. 

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

Küng, K., Aeschbacher, K., Rütsche, A., Goette, J., Zürcher, S., Schmidli, J., & Schwendimann, R. (2021). Effect of barcode technology on medication preparation safety: A quasi-experimental study. International Journal for Quality in Health Care33(1).  

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Profetto, L., Gherardelli, M., & Iadanza, E. (2022). Radio Frequency Identification (RFID) in Health Care: Where are we? A scoping review. Health and Technology12(5), 879–891.  

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

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