Adverse Event or Near-Miss Analysis
Madical arrora on part of the healtheare providers due to lack of attantion result in adverse avanta or near-miss aventa. These events
are preventable errors that can be minimized by providing healthcare providers with additional help through the Introduction of
tachnological ald.

Implications of an Adverse Event

An advarse occurred In the healtheare astup whara I work which resulted In fatalltles. The adverse event was due to a medlcation error
on part of the prescriber who had mistakenly administared a drug that led to an Instant decreasa In blood pressure and the patlent
underwant savare hypotenalve erises which Induced a coma In the patlent.

Thia advarse avant hurt the staksholdars (patlents and the hoapltar). Following this Incldent, many the number off patlanta who cama
to recelve healthoare services decreased drastically. The hospltal began to lose Its financlal, soclal, and aconomle standing as more of
Ita patlenta siarted to get healthoare services from other hoapltals.

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

Short-term and Long-term effects for Stakeholders

The short effact la that the patlent will be unsatlaffed, thay will be cautlous of the care that they will racelve at the hospltal and the
healtheare providers will be demorallzed by thelr Inabllity to prevant the medication eror that andangared the patlent’a Iife. The long-
tarm affect will be the lack of patlenta willing to reguire healtheare services from the hoapltal. In the healtheare system, the Investora
and owners will go bankrupt and will lose thelr businesa as the patlent would not ragulre healtheare sarvices from It.

Assumptions
The analysla la based on the assumption that the healtheare providara due to belng overburdaned make madical arrora that laad to
fatalitles, mortallty, and morbidity rate. As a result, patient dlssatsfaction Incraases and patlents refuse to racelve treatment from the
same hoapltal.

The sequence of Events/ Missed Steps
The saguence of events that led to the advarse event Involved the lack of abllity of the healtheare providars to evaluate and assess the
effect of the druga which were to be administared to the patlenta. The cardlologist came, assessed the patlent’s emergency condition,
and prescribed the druga that needed to be administered. The cardiologlat was In a hurry and needed to attend to othar patlenta, dua
to which he prescribed the wrong medieatlon (mlased step 1). The nursea were Instructed to follow the prescripton and since they did
not have anough knowledge to guestion the drug preseribed, they blindly adminstered the patlant with medication (mlased step 2).

The mediclna which was administered was Sodlum Nitroprusaide which Instantly decreased the patlent’a blood pressure and Induced
a coma. The patlent already hed low blood prassura and nesded traatmant for It, Instead of prescribing Atroplna, the cardiologlst
prescribed Sodlum Nitroprusslde which Is administered in case of sevare high blood pressure. The patlent was shifted to ICU
(Intenslve Care Lnit) to nullity the effact of the drug.

The above-mantloned missed stepa were responalble for the adverse avant which occurred. The factor which contributed to the
advarse avant waa the overburdan of the healtheara providera which resulted In a lack of time management of the healtheare
providara. The lack of managament resulted In the wrong prescription of the drugs which led to advarse eventa and andangared the
patient’s Ilfe.

Knowledge Gaps
Another missed step was the lack of knowledge of nurses ragarding the medication which are prescribed. They do not know the
pharmacologloal and pharmacodynamlc effecta of the medicationa and adminlater them to the patlent. As a result, adverse evana
occur which andanger the Iife of the patlent.

Quality Improvement Actions or Technologies
Quallty Improvement (0) actiona ara needed to prevent advarse avants and near-mlan avanta which endanger the patlent’a IIfe. The Ql
tachnologles which can be Implemented to raduce adverse aventa Include the Implamantatlon of an Electronic Health Record (EHR)
system. Along with thla, the Q action which can be Implemanted in the healtheare centar to reduce the chances of adverse aventa and
medication errors Includa the aducation of healtheare providers especlally the nurses about the druga (Holmgren at al, 2020).

Thla knowledge will help the nurses to be profielent to an extent that when medicationa ara prescribed the nurses can analyze, assess
and avaluate If the drug prescribed by the phyaiclan or the speclallat la correct or not. Along with thia, the aducation of nursing staff to
be caraful, cautloua, and active whlle monitoring the patlant. This will allow tham to be knowledgeable about the signa and symptoma
whch correspond to an emargancy condition that will amplify due to adverse affacta of the medication therapy. Thia will help to
pravant adverse event-ed amergencles that Incraase mortallty and morbidity rates for the patlenta. Both of these Ql actiona and
tachnologles are regulred to reduce the riak to the patlenta Iife and to ensura patlent safaty (Mardanl st al, 2020).

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

Criteria

The eriterla which will be used to avaluate the actiona or technologles will be the reduction In the number of madicatlon arrora and
adverse avanta which have occurred. The reduction In the freguency of the events will pose eriterla for evaluation of the affectivaness
and safaty of the Ql actlona and technologles (Gates at al, 2021).

Quality Improvement Initiative
The proposed quallty Improvamant Initlative to prevent adverse events Includes the use of an EHR system. The Introduction of the EHR
system will halp healtheare providera to countercheck the medicatlona which thay prescribe. It will halp to countercheck the
concantration of the drug which are prescribed. Through Ita updated systam, the EHR system will check for Interactiona that the drug
will have, and If it Is contraindicated In the patient’s respective patlant’s conditions.

The EHR systam will also have an Inbullt alarm or waming systam which will ansure that If any adverse event la about to occur or Ia
expected to happen, the EHR system will Initlate a sarles of alarm or waming systama that will warn the healtheare providers about the
advarse avant. As a result, It will help to prevent advarse eventa or near-miss avanta from happening (Valdotas at al,, 2019).

The EHR systam comes egulpped with a monltoring system that monltors the health of the patlent throughout the tharapy seasion.
Thia allows for the affective prevention of medication emors, advarse avents, or near-miss events which may occur. The monltoring
system keepa the healtheare providers In the loop of the patient’s condition and ansures no harm la Inflicted on the patlent’s health
(Carayon at al, 2021).

The healtheare syatem should also encourage healtheara providars to work In collaboration and communicata with team membars to
pravant adverse eventa. Thay should be palred In teams to encourage counterchecking of each sap starting from preseription and
dlapansing, to administration. All sapa should be counterchecked to prevent arrora and to ensure that the corract medication la balng
prescribed, dlapansad, and adminlstered (Irajpour et al, 2019).

Haaltheare providers should also be ancouraged to leam about the Interaction between druga, thelr pharmacological pathways, thalr
advarse evanta, and the patlent population which should not be administered these medicationa. Along with thla, aducation,
avallablity, and accessibllity of the antidotes to the medicationa such be avallable In the emargancy room (ER). All of the necesaary
Ifesaving drugs, machlnary, and eguipmant should be avallable In the ER to provide the patient wtth Instant care to prevent the
dagradation of health (Hanson & Haddad, 2022).

Conflicting Data

Confficting data ragarding the use and Implamantation of EHR systema In pravaning madication errors ls that some glitches In the
system prevent the effactive recognition of medieation errors, adverse events, or near-miss events. Thia hampers the abllity of the EHR
system to provide safe and guality care sometimes. The EHR system also haa privacy protection Issues Iinkad to patlant Information
that contribute to the unsafe use of electronie health services (Basil at al,, 2022). Another conflicting data la that the healtheare
providars are not willing to learn about the tachnological ald to Increase the affectiveness of the therapy and to prevent medication
arrors.

Conclusion

Adverse aventa and near-mlsa avanta occur due to the lack of attantion from healtheare providers. These events are preventable and
can esally be pravanted from happening If healtheara providers are educated about the Importance of double-checking and the
Introduction of an EHR system.

References

Basll, N. N., Ambe, S., Ekhator, G., & Fonkem, E. (2022). Health recorda database and Inherent securlty concerna: A reviaw of the
Iterature. Curaus, 14(10), e30168. httpa/dol.org/10.7759/cureua.30168

Carayon, P, Du, S., Brown, R., Cartmlll, R., Johnson, M., & Wetternack, T. B. (2017). EHR-related medication arrors In two ICUs. Joumal of
Healtheare Risk Managament: The Joumal of The American Soclety for Healthoare Rlak Management, 36(3), 6-15.
httpa://dol.org/10.1002/jhrm.21259

Gates, P. J., Hardle, R. A, Raban, M. Z, LI, L, &. Westbrook, J. I. (2021). How effactive are electronle medication systema In raducing
madication error raten and assoclated harm among hoapltal Inpatlenta? a syatematic review and meta-analysls. Joumal of the
American Medical Informatics Assoclation: JAMIA, 28(1),67-176. httoa:00679/101093⑇)⑆m2⑇0099230