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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 Date 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 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: 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