Name: Capella University
Instructor’s name
October 2023

Adverse Event or Near-Miss Analysis

This assessment delves into a critical analysis of an adverse event scenario in a healthcare setting, with the objective of identifying the root causes, implications, and areas of improvement needed to enhance patient safety and reduce the risk of similar incidents. The scenario under consideration involves a near miss due to a medication administration error at Vila Healthcare Hospital. Through a thorough examination of the sequence of events, protocol deviations, knowledge gaps, and uncertainties associated with this event, this assessment aims to impartially consider conflicting data and perspectives in order to outline a Quality Improvement (QI) initiative. This initiative seeks to address the systemic vulnerabilities highlighted and provide an effective, multifaceted solution to prevent future adverse events or near misses in the healthcare environment.

Patient Scenario

At Vila Healthcare Hospital, I found myself in a challenging situation as a nurse while attending to Sarah, a 45-year-old patient who had recently undergone abdominal surgery. Sarah had a complex medical history, including allergies to specific antibiotics. I was responsible for administering her post-surgical antibiotics, ensuring I used the alternative antibiotic that she wasn’t allergic to. However, on that particular evening, our hospital’s electronic health record system was experiencing technical difficulties. I couldn’t access Sarah’s digital medical records, including her allergy information. Feeling the pressure of time and the urgency of administering the antibiotics, I decided to consult the paper-based patient records, which were stored in a separate room. As I was leaving Sarah’s room to retrieve the paper records, a code blue was announced over the hospital’s intercom system, indicating a cardiac arrest in another wing of the hospital. With a heavy heart, I left Sarah’s room and headed to assist with the emergency. When I returned to Sarah’s room after helping stabilize the other patient, I was determined to administer the antibiotics. However, due to the chaos in the ward during the code blue situation, I inadvertently used the standard antibiotic from the automated dispensing system instead of the alternative one listed in her paper records. Unbeknownst to me, the system had temporarily overridden the alert regarding her antibiotic allergy due to the ongoing technical issues with the electronic health records. After the antibiotic administration, Sarah quickly developed an allergic reaction, including severe hives, shortness of breath, and a drop in blood pressure. The situation escalated, and we had to initiate an emergency response, administering epinephrine and antihistamines to counteract the reaction. Fortunately, Sarah’s condition stabilized after these interventions, but the incident served as a stark reminder of the vulnerabilities in our healthcare system, with technology failures, distractions, and interruptions contributing to near misses

Implications of the Adverse Event for Stakeholders

The event described in the scenario has significant implications for various stakeholders involved, each with their own set of concerns and considerations. For the patient, Sarah, the implications are critical, as she experienced an allergic reaction due to the administration of the wrong antibiotic. This event not only jeopardized her immediate health and well-being but also raised concerns about her confidence in the healthcare system and the quality of care she receives at Vila Healthcare Hospital. For Sarah’s family, the incident likely triggered emotional distress, worry, and potential mistrust in the hospital’s care protocols. They may question the safety and reliability of the hospital, raising concerns about whether their loved one is receiving the best possible care.

The hospital staff, including the nurse involved, the medical team, and other healthcare professionals, were also significantly impacted. The nurse involved is likely to experience guilt, stress, and anxiety about the near miss, potentially leading to a decline in her confidence and morale. The incident may affect the trust and working relationships among the healthcare team members, leading to concerns about their ability to provide patient-centered care and avoid similar errors in the future. Furthermore, Vila Healthcare Hospital itself faces potential legal and reputational consequences, as the event may raise questions about its commitment to patient safety and its adherence to healthcare standards and regulations (Harrison et al., 2019).

Assumptions underlying this analysis include that the event described in the scenario is representative of a real-world healthcare system, where electronic health record systems may experience technical difficulties, patients have complex medical histories, and healthcare professionals are subject to high-pressure and interruption-prone environments (Scantlebury et al., 2021). It also assumes that the consequences and reactions described are typical of such incidents, including potential emotional distress for patients and their families, as well as professional and institutional repercussions for the hospital and healthcare staff (Scantlebury et al., 2021). The analysis considers the need for a Quality Improvement (QI) initiative based on the assumption that this event highlights systemic vulnerabilities and suggests the potential for improving patient safety and healthcare quality.

Adverse Event with Root Cause Analysis

A root cause analysis of the adverse event in the scenario reveals a sequence of critical events and protocol deviations that contributed to the near miss. First, the electronic health record system’s technical issues impeded access to the patient’s critical allergy information, creating an initial knowledge gap (Phadke et al., 2022). The nurse’s decision to consult paper-based records was a logical step; however, the interruption caused by the code blue call led to a missed step, as the nurse left the patient’s room before verifying the correct antibiotic. Furthermore, there was a protocol deviation when the automated dispensing system temporarily overrode the allergy alert due to the technical issues, leading to the administration of the wrong antibiotic (Phadke et al., 2022).

Uncertainties and knowledge gaps in this analysis include the extent of the technical issues with the electronic health record system, whether there were established protocols for handling such system failures, and the specifics of the electronic system’s interaction with the automated dispensing system. Additionally, the analysis does not provide details about how the code blue incident affected the nurse’s workload or time management, leaving unanswered questions about the hospital’s staffing levels, training for multitasking, and the presence of clear interruption protocols (Linthoingambi & Agarwal, 2021). 

Evaluation of Quality Improvement Technologies

To reduce risk and enhance patient safety in light of the scenario, several quality improvement actions and technologies are required. First, the implementation of a more robust and redundant electronic health record system is crucial (Cícero et al., 2023). This system should not only be resilient in the face of technical issues but also feature clear alerts and reminders related to patient allergies and medication interactions. The criteria to evaluate this technology would include its reliability during system disruptions, its user-friendliness, and its effectiveness in preventing medication errors. Additionally, the integration of barcode scanning technology can be instrumental in ensuring the right medication is administered to the right patient, providing an added layer of safety (Cícero et al., 2023).

A second important quality improvement action involves enhancing healthcare team training and protocols for managing interruptions and multitasking. This would include the development of specific interruption management protocols and guidelines for prioritizing tasks during emergencies. The criteria for evaluating this action would include the degree to which healthcare professionals can effectively manage interruptions without compromising patient safety, and the reduction in medication errors or near misses related to multitasking (Curtin et al., 2020). Moreover, the hospital should foster a culture of open communication and a non-punitive approach to reporting near misses, encouraging staff to share their experiences and contributing to continuous learning and improvement in patient safety. The criteria for evaluating this cultural change would include the increase in near-miss reporting, a reduction in repeat incidents, and improved collaboration among healthcare professionals to prevent future errors (Curtin et al., 2020).

Quality Improvement Initiative to Prevent a Future Adverse Event or Near Miss

A comprehensive Quality Improvement (QI) initiative is essential to prevent future adverse events or near misses like the one described in the scenario. This initiative should begin with a root cause analysis to identify systemic vulnerabilities, knowledge gaps, and areas of uncertainty (Rao, 2020). To impartially consider conflicting data and perspectives, a multidisciplinary team consisting of healthcare professionals, including nurses, doctors, pharmacists, and IT specialists, should be involved. This team will collaborate to create a proactive plan focused on the following key components:

Technology Enhancement 

The QI initiative should prioritize upgrading the hospital’s electronic health record system to ensure resilience during technical issues and to provide robust allergy and medication interaction alerts. This should involve collaborating with healthcare IT specialists to implement a system that minimizes interruptions during critical tasks (Scantlebury et al., 2021). The team should assess different available technologies, considering their effectiveness, cost, and adaptability to the hospital’s existing infrastructure.

Staff Training and Protocols

Develop and implement comprehensive staff training programs that address the management of interruptions and multitasking (Westbrook et al., 2019). Conflicting data and perspectives should be impartially considered during the design of these programs, ensuring they account for the realities of healthcare professionals’ workloads. Protocols should also be established to guide staff on how to handle interruptions and prioritize tasks during emergencies. Regular refresher courses and updates should be provided to ensure that staff are well-prepared to manage high-pressure situations (Westbrook et al., 2019). Additionally, a robust near-miss reporting system should be established, ensuring the impartial collection of data and perspectives to identify recurring issues and areas for improvement.

Conclusion

The analysis of the adverse event scenario at Vila Healthcare Hospital highlights the critical need for quality improvement measures to enhance patient safety and reduce the risk of similar incidents in healthcare settings. By impartially examining the sequence of events, protocol deviations, and the knowledge gaps associated with the incident, this assessment has identified the importance of strengthening the electronic health record system, improving staff training and protocols for managing interruptions, and fostering a culture of open communication and reporting. These measures can collectively contribute to a healthcare environment that is better equipped to prevent medication errors and near misses, ultimately ensuring the well-being and safety of patients. The multifaceted Quality Improvement initiative proposed here serves as a proactive approach to address the systemic vulnerabilities, thus reinforcing the commitment to providing high-quality and safe patient care.       

References

Cícero, L., Silva, & Eduardo. (2023). Improving patient safety using technology. Revista Gênero E Interdisciplinaridade, 4(02), 173–183. https://doi.org/10.51249/gei.v4i02.1324 

Curtin, A. G., Anderson, V., Brockhus, F., & Cohen, D. R. (2020). Novel team-based approach to quality improvement effectively engages staff and reduces adverse events in healthcare settings. BMJ Open Quality, 9(2), e000741. https://doi.org/10.1136/bmjoq-2019-000741 

Harrison, R., Sharma, A., Walton, M., Esguerra, E., Onobrakpor, S., Nghia, B. T., & Chinh, N. D. (2019). Responding to adverse patient safety events in Viet Nam. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4518-y 

Linthoingambi, L., & Agarwal, R. (2021). Prospective analysis of the code blue system in a tertiary care hospital. International Journal of Scientific Research, 26–30. https://doi.org/10.36106/ijsr/2309472 

Phadke, N. A., Wickner, P., Wang, L., Zhou, L., Mort, E., Bates, D. W., Seguin, C., Fu, X., & Blumenthal, K. G. (2022). Allergy safety events in health care: Development and application of a classification schema based on retrospective review. The Journal of Allergy and Clinical Immunology: In Practice, 10(7), 1844-1855.e3. https://doi.org/10.1016/j.jaip.2022.03.026 

Rao, S. (2020). Quality improvement in the NHS. SUSHRUTA Journal of Health Policy & Opinions, 11(1), 17–18. https://doi.org/10.38192/11.1.6 

Scantlebury, A., Sheard, L., Fedell, C., & Wright, J. (2021). What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study. Digital Health, 7, 205520762110100. https://doi.org/10.1177/20552076211010033 

Westbrook, J. I., Raban, M. Z., & Walter, S. R. (2019). Interruptions and multitasking in clinical work: A summary of the evidence. Health Informatics, 103–114. https://doi.org/10.1007/978-3-030-16916-9_7 

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