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

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

Adverse Event or Near-Miss Analysis

The Adverse Event or Near-Miss Analysis is done following an adverse event or nearly missed case analysis.
Errors caused by the healthcare providers due to inattention that end up inletoning adverse events or near-miss eventsform one of the challenges. These events are mistakes which cause as a result of being overwhelmed emotionally and physically. If there is enough technological support, we could make things better and reduce the number of preventable mistakes.

Vast consequences resulting from a Unfavorable Incident

One of unusual events took park in the healthcare facility where I work that resulted in fatality. The adverse event happened because of the mistake from the prescriber who was not competent enough to recognize that he or she had administered the wrong drug that eventually led to an immediate drop in blood pressure with severe hypotensive crisis and the patient went into a coma instantly.

This negative outcome was among some of the stakeholders in the hospital (patients and healthcare providers). Subsequently, after that happen, a lots of clients stopped visiting health centers to receive healthcare. The clinic started to diminish in reputation and vital indicators of its profitability, interpersonal relations, and economic stability as some patients instead went elsewhere.

Short-term and Long-term effects for Stakeholders

Spillover and Long-term and convergent effects for the stakeholders
However, the immediate outcome will be that the patient will not be happy because they were not helped as they expected. They will not be pleased with the care service of the hospital and the professionals will be demoralized because their prevention efforts failed to protect the patient’s life. The environment will lead to the wealth of patients not agreeing to seek medical attention from the facility. As for health system, investor and owners of healthcare cannot survive at the completion of phase and the patients would not require the system anymore to provide them their healthcare services.


The analysis is conducted under the hypotheses that the healthcare providers due yo the excess of work make medical error which complicates patients’ treatment and increase mortality and morbidity rate. Consequently, the overall level of patient satisfaction plummets and patients who have been previously treated in their hospital, quit getting treatment from the same institution.

The Sequence of Events/ Missed Steps 

Course of that patient care exposition included inability of the prescribing healthcare providers to evaluate and assess the respective drugs which were going to be administrating to the patients. The cardiologist arrived, examined and diagnosed the patient’s critical condition and went on with the emergent prescription for the patient, which included drugs and dosage. The cardiologist was in a hurry and hence he had to follow up with other patients. He, therefore, prescribed the wrong medication (disclosing the missed step 1). The nurses’ strict crew leaders were to play commanding role by following the drugs prescribed; however, they were not adequately knowledgeable to question the drugs; and, therefore, they meekly administered the patients with medications (retired step 2).

The drug which was prescribed was Sodium Nitroprusside that worked to drop the patient’s blood pressure levels and caused the patient to lose consciousness. The patient had hypotension and drug Therapy. Atropine is not effective for him and thus, Cardiologist prescribe Sodium Nitroprusside for him.

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

Another missed step was the lack of knowledge of nurses regarding the medication which are prescribed. They do not know the pharmacological and pharmacodynamic effects of the medications and administer them to the patient. As a result, adverse events occur which endanger the life of the patient.

Quality Improvement Actions or Technologies

Quality Improvement (QI) actions are needed to prevent adverse events and near-miss events which endanger the patient’s life. The QI technologies which can be implemented to reduce adverse events include the implementation of an Electronic Health Record (EHR) system. Along with this, the QI action which can be implemented in the healthcare center to reduce the chances of adverse events and medication errors include the education of healthcare providers especially the nurses about the drugs (Holmgren et al., 2020).

This knowledge will help the nurses to be proficient to an extent that when medications are prescribed the nurses can analyze, assess, and evaluate if the drug prescribed by the physician or the specialist is correct or not. Along with this, the education of nursing staff to be careful, cautious, and active while monitoring the patient. This will allow them to be knowledgeable about the signs and symptoms which correspond to an emergency condition that will amplify due to adverse effects of the medication therapy. This will help to prevent adverse event-led emergencies that increase mortality and morbidity rates for the patients. Both of these QI actions and technologies are required to reduce the risk to the patient’s life and to ensure patient safety (Mardani et al., 2020).

Quality Improvement Initiative 

The proposed quality improvement initiative to prevent adverse events includes the use of an EHR system. The introduction of the EHR system will help healthcare providers to countercheck the medications which they prescribe. It will help to countercheck the concentration of the drug which are prescribed. Through its updated system, the EHR system will check for interactions that the drug will have, and if it is contraindicated in the patient’s respective patient’s conditions. 

The EHR system will also have an inbuilt alarm or warning system which will ensure that if any adverse event is about to occur or is expected to happen, the EHR system will initiate a series of alarm or warning systems that will warn the healthcare providers about the adverse event. As a result, it will help to prevent adverse events or near-miss events from happening (Vaidotas et al., 2019). 

The EHR system comes equipped with a monitoring system that monitors the health of the patient throughout the therapy session. This allows for the effective prevention of medication errors, adverse events, or near-miss events which may occur. The monitoring system keeps the healthcare providers in the loop of the patient’s condition and ensures no harm is inflicted on the patient’s health (Carayon et al., 2021). 

The healthcare system should also encourage healthcare providers to work in collaboration and communicate with team members to prevent adverse events. They should be paired in teams to encourage counterchecking of each step starting from prescription and dispensing, to administration. All steps should be counterchecked to prevent errors and to ensure that the correct medication is being prescribed, dispensed, and administered (Irajpour et al., 2019). 

Healthcare providers should also be encouraged to learn about the interaction between drugs, their pharmacological pathways, their adverse events, and the patient population which should not be administered these medications. Along with this, education, availability, and accessibility of the antidotes to the medications such be available in the emergency room (ER). All of the necessary lifesaving drugs, machinery, and equipment should be available in the ER to provide the patient with instant care to prevent the degradation of health (Hanson & Haddad, 2022). 

Conflicting Data

The contradiction is that while the EHR system’s glitches prevent proper detection of medication errors, adverse events, or near miss events, success of this is still being kept an open debate. This increase the possibility of errors in the EHR system since it may not provide the desired level of safe and quality healthcare services. The system of Electronic Health Record (EHR) also raises the safety issues of patients by linking those patients’ information that may be the cause of the unsafe use of electronic health care services (Basil et al., 2022). One of the controversies to this discussion is that the healthcare workers are not willing to learn about technology in the field so they can effectively accomplish the target and prevent the medication errors.

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

Adverse events and near-miss events occur due to the lack of attention from healthcare providers. These events are preventable and can easily be prevented from happening if healthcare providers are educated about the importance of double-checking and the introduction of an EHR system. 

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