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The Medical Complications Essay Assignment Paper

The Medical Complications Essay Assignment Paper

The near miss event that one of my peers caught was when another nurse was about to hang a bag of insulin instead of the the antibiotic zosyn that was prescribed. this can be the introduction then the rest of the paper can focus on the other facilities that have had similar near misses

note the highlighted areas In the instructions. BE sure to talk about a quality improvement initiative

included below are some resources you can use to find the reported data on near misses , etc

-Agency for Healthcare Research and Quality. (2021). WebM&M: Case studies. https://psnet.ahrq.gov/webmm

-U.S. Food & Drug Administration. (n.d.). FDA adverse event reporting system (FAERS). https://www.fda.gov/Drugs/InformationOnDrugs/ucm135151.htm

-Centers for Medicare & Medicaid Services. (2020). Core measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-Measures The Medical Complications Essay Assignment Paper

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Adverse Event or Near-Miss Analysis

Interprofessional communication is a vital component of the health care system. Communication can be defined as the exchange of information among health care professionals. It includes verbal, non-verbal, written, and electronic communication. Interprofessional communication is essential for the effective delivery of care to patients. Adverse events and near-misses are often the result of ineffective communication. An adverse event is when an event that is unintended and could be harmful or fatal occurs as a result of the care provided to a patient. A near-miss is an event that could have been harmful or fatal but was not. The near miss event that one of my peers caught was when another nurse was about to hang a bag of insulin instead of the antibiotic zosyn that was prescribed. If the other nurse had caught the mistake, it may have resulted in a patient getting an antibiotic that was not meant for them, and this could have led to a medical error.

Analysis of Implications of Near Miss All Stakeholders

The near miss that could have resulted in a wrong administration of medication could have had serious consequences for the patient. The interprofessional team involved in the incident may have been held responsible for not properly verifying prescribed medications, and as a result, the patient could have received the wrong medication. There could have been serious consequences for the team, such as disciplinary action. The team may also have had to take measures to ensure that this does not happen again, such as monitoring prescription medications more closely. In terms of the impact on stakeholders, this incident could have resulted in increased anxiety and stress for the patient and their family. It could also cause them to worry about medication errors, which could affect how they interact with medical professionals (Trakulsunti et al., 2021)The Medical Complications Essay Assignment Paper. The team may have to take measures to reassure the patient and family that such incidents will not happen again. Finally, this incident may impact how other stakeholders, such as doctors and nurses, report their work. They may feel more cautious about prescribing medications or performing medical procedures. There could be a negative impact on the quality of care that patients receive. The impact on stakeholders could depend on a variety of factors, such as the nature of the incident, the role of the team involved, and how widely it is reported. For instance, the near-miss event may have a more negative impact on frontline staff such as nurses, who are usually responsible for verifying prescriptions, than it would on doctors or other senior team members. The nurses may be more likely to share their concerns with other staff members, which could lead to a wider awareness of the dangers of medication errors (Trakulsunti et al., 2021). The impact on stakeholders will also depend on how well the team responds to the incident. If they take steps to reassure the patient and family, for instance, then the impact may be limited. However, if the team does not take sufficient measures to address the concerns of the patient or family, then the fallout could be more significant.

Analysis of the Sequence of Events, Missed Steps, or Protocol Deviations Related to the Near Miss Using a Root Cause Analysis

If the near miss event occurred as a result of incorrect patient identification, then the event could be attributed to human error. However, if the near miss event occurred as a result of an incorrect antibiotic prescription, then it is likely that the event was due to a protocol deviation (Gopa et al., 2019)The Medical Complications Essay Assignment Paper. In this case, it is important to determine why the antibiotic prescription was incorrect in order to prevent similar errors from occurring in the future. In the case of near-miss event, if the insulin was to be prescribed instead of antibiotic zosyn, it could have led to a medical error. Medical errors in hospitals continue to be a problem, and it is important to identify the root cause of these errors in order to improve patient safety. In this case, the incorrect prescription could have been due to confusion over which antibiotic was being prescribed, or the nurse may have been unfamiliar with the zosyn medication. In order to prevent such errors from happening in the future, it is important to have standardized patient identification and medication prescribing processes in place.

The missed steps or protocol deviations that led to the near miss described is that the nurse was about to hang a bag of insulin instead of the antibiotic zosyn that was prescribed. The oversight could have been due to the nurse not reading the prescription carefully enough or not verifying that the patient needed zosyn instead of insulin (Gopa et al., 2019). The reason for this oversight could be due to the nurse being distracted or not having enough time to properly complete the task. It is important that nurses are meticulous in their reading and writing of medications in order to avoid any potential near miss events.

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Interprofessional communication could have been improved due to the nurse not speaking up or alerting their colleague of the mistake. By speaking up, the nurse could have potentially prevented a potential conflict or potential error (Rodziewicz & Hipskind, 2020)The Medical Complications Essay Assignment Paper. The nurse should be vocal and alert their colleagues of any potential errors so that they can take the appropriate corrective actions. This would have prevented the near miss event from occurring, and therefore, the near miss event was preventable.

Quality Improvement Actions or Technologies Related to the Near Miss

Quality improvement technologies that can help reduce risks and increase patient safety related to this near-miss event that could have resulted in a medical error include using a data-driven approach to diagnosing and treating patients, using patient safety monitoring tools (PSMTs) to monitor and identify trends in patient safety, and implementing risk-based decision-making processes. The data-driven analytics tools that can be helpful in this situation include machine learning and artificial intelligence tools, which can help identify patterns in patient safety data (Gopa et al., 2019). Additionally, PSMTs can provide a comprehensive picture of patient care across an entire hospital, which can provide valuable insights into areas such as readmission rates and patient satisfaction. Implementing risk-based decision-making processes can help identify areas where risks are highest and make changes to patient care protocols accordingly, reducing the likelihood of future medical errors. Due to the near miss event that was about to take place, these technologies are not being utilized appropriately at this time. However, as the hospital implements these technologies and learns more about how to use them effectively, it is likely that they will be able to reduce risks related to patient safety in the future (Gopa et al., 2019)The Medical Complications Essay Assignment Paper. Other institutions prevent medical errors like one described in the case by identifying potential errors and then correcting them. They also have quality improvement technologies in place to reduce risk and increase patient safety. In addition, they look to other data sources outside of the institution to help make informed decisions. For example, they might look at hospital readmission rates to see if there is a correlation between adverse events and subsequent patient safety risks. The data that could have been generated from the facility’s dashboard related to the near-miss might include metrics like patient satisfaction, readmission rates, and mortality rates. It is important to look at these data to see if they are trending in a positive or negative direction.

There is a wealth of research and data available outside of an institution that could be used to improve patient safety. For example, there is research that has been done on how patient satisfaction impacts safety outcomes (Gopa et al., 2019). Additionally, there is research that has been done on how patient satisfaction impacts the likelihood of returning to the same hospital in the future (Rodziewicz & Hipskind, 2020)The Medical Complications Essay Assignment Paper. Other types of data that could be used to improve patient safety include data on how hospital budget impacts patient safety outcomes, data on how hospital staffing impacts patient safety outcomes, and data on how the type of surgery performed affects patient safety. Both the internal and external data can be used to improve patient safety by informing decision making, improving hospital policies and procedures, and altering patient care.

Quality Improvement Initiative

The incident was managed by having the nurse double check the medication before administering it and reporting the near miss event to the institution’s quality assurance department. Quality improvement initiatives that have been shown to work are educational programs that teach nurses about how to identify and prevent healthcare errors, developing standard operating procedures that are followed by all staff members, and having a system in place to immediately report any adverse events or near misses (Rodziewicz & Hipskind, 2020)The Medical Complications Essay Assignment Paper. Elements that can be applied to prevent future adverse events or near misses are having staff members train on how to identify and prevent healthcare errors, developing standardized operating procedures, and having a system in place to immediately report any adverse events or near misses. There is evidence that educational programs, standardized operating procedures, and a system in place to immediately report any adverse events or near misses are successful in preventing future adverse events or near misses. However, further research is needed to determine which of these interventions is the most effective in preventing future adverse events or near misses.

Conclusion

Administering the wrong medication can lead to serious medical errors, including reactions to medication, delayed treatment, and even death. In this case, if the nurse had not caught the near miss, the patient may have received the wrong medication and ended up with a serious reaction. This could have resulted in serious medical complications and even death. By catching the near miss, the nurse averted a potential tragedy and prevented a potentially harmful error from happening. This is an important lesson to remember when it comes to medical care – vigilance is key! Nurses should ensure that they are always aware of the medications that they are administering and make sure that they are correctly following any prescribed protocols. This way, they can prevent potentially harmful errors from happening and ensure that their patients receive the best possible care The Medical Complications Essay Assignment Paper.

References

Gopal, G., Suter-Crazzolara, C., Toldo, L., & Eberhardt, W. (2019). Digital transformation in healthcare–architectures of present and future information technologies. Clinical Chemistry and Laboratory Medicine (CCLM), 57(3), 328-335.

Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

Trakulsunti, Y., Antony, J., Dempsey, M., & Brennan, A. (2021). Reducing medication errors using lean six sigma methodology in a Thai hospital: an action research study. International Journal of Quality & Reliability Management, 38(1), 339-362.

Assessment 1 Instructions: Adverse Event or Near-Miss Analysis

Top of Form

Bottom of Form

  • Prepare an analysis (5-7 pages) of an adverse event or a near miss from your professional nursing experience and outline a QI initiative that would address it.

Introduction

Health care organizations strive to create a culture of safety. Despite technological advances, quality care initiatives, oversight, ongoing education and training, legislation, and regulations, medical errors continue to be made. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation. Many errors are attributable to ineffective interprofessional communication. The Medical Complications Essay Assignment Paper

Overview

The goal of this assessment is to allow you to focus on a specific event in a health care setting that impacts patient safety and related organizational vulnerabilities and to propose a QI initiative to prevent future incidents. It will give you the chance to develop your analytical skills in the problem-solving contexts you likely find yourself in as a health care professional.

Health care organizations strive for a culture of safety. Yet, despite technological advances, quality care initiatives, oversight, ongoing education and training, laws, legislation, and regulations, medical errors continue to occur. Some are small and easily remedied with the patient unaware of the infraction. Others can be catastrophic and irreversible, altering the lives of patients and their caregivers and unleashing massive reforms and costly litigation.

Historically, medical errors were reported and analyzed in hindsight. Today, QI initiatives attempt to be proactive, which contributes to the amount of attention paid to adverse events and near misses. Backed up by new technologies and reporting metrics, adverse events and near misses can provide insight into potential ways to improve care delivery and ensure patient safety.

For clarification, the National Quality Forum (n.d.) defines the following:

    • Adverse event: An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.
    • Near miss: An event or a situation that did not produce patient harm, but only because of intervening factors, such as patient health or timely intervention. The Medical Complications Essay Assignment Paper

Instructions

Prepare a comprehensive analysis of an adverse event or a near miss from your professional nursing experience that you or a peer experienced. Provide an analysis of the impact of the same type of adverse event or near miss in other facilities. How was it managed, who was involved, and how was it resolved? Be sure to:

    • Analyze the implications of the adverse event or near miss for all stakeholders.
    • Analyze the sequence of events, missed steps, or protocol deviations related to the adverse event or near miss using a root cause analysis.
    • Evaluate QI actions or technologies related to the event that are required to reduce risk and increase patient safety.
      • Evaluate how other institutions integrated solutions to prevent these types of events.
      • Incorporate relevant metrics of the adverse event or near miss to support need for improvement.
    • Outline a QI initiative to prevent a future adverse event or near miss.
    • Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Be sure your analysis addresses all of the above points. You may also want to read the Adverse Event or Near Miss Analysis Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Adverse Event or Near Miss Analysis [DOCX] document for additional clarification about things to consider when creating your assessment. The Medical Complications Essay Assignment Paper

Additional Requirements

Your assessment should also meet the following requirements:

    • Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page or References section.
    • Number of references: Cite a minimum of three sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master’s Program (MSN) Library Guide for guidance.
    • APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.

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Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

    • Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.
      • Analyze the implications of an adverse event or a near miss for all stakeholders.
      • Analyze the sequence of events, missed steps, or protocol deviations related to an adverse event or a near miss using a root cause analysis.
      • Outline a quality improvement initiative to prevent a future adverse event or near miss based on research and evidence-based practices.
    • Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
      • Evaluate and identify quality improvement actions or technologies related to an event that are required to reduce risk and increase patient safety.
    • Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
      • Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Reference

National Quality Forum. (n.d.). NQF patient safety terms and definitions. http://www.qualityforum.org/Topics/Safety_Definitions.aspx The Medical Complications Essay Assignment Paper