Student Name
Capella University
NURS-FPX 6016 Quality Improvement of Interprofessional Care
Prof. Name
Date
Adverse Event or Near-Miss
Near-miss incidents and adverse events in healthcare are critical indicators of systemic vulnerabilities and provide valuable insights for improving patient safety. This analysis focuses on a near-miss medication error involving acetaminophen. During a pediatric shift at Saint Mary Hospital, a nurse identified that a patient had received an additional dose of acetaminophen. This event highlights the importance of standardized protocols, effective communication, and careful verification at each step of medication administration (Mulac et al., 2020). This discussion examines the consequences of the incident, the sequence of actions, root cause analysis, and outlines a quality improvement (QI) initiative aimed at reducing the likelihood of future medication errors.
Implications for Stakeholders
During a busy shift in the pediatric unit, Nurse Emily administered an extra dose of acetaminophen to James, a 7-year-old with a mild ear infection and fever. The error occurred during the handoff between the day and night shift nurses, where the latter did not verify the Medication Administration Record (MAR) in the Electronic Health Record (EHR). Critical information regarding James’s prior dose was not communicated. Three hours after the administration, James displayed mild drowsiness. Close monitoring prevented serious harm, but the incident revealed significant gaps in communication, medication reconciliation, and verification protocols.
Implications
This incident has both immediate and long-term consequences for multiple stakeholders, including the patient, family, healthcare team, and the organization.
- Patient and Family: The family experienced stress and potential loss of confidence in the hospital’s safety measures. Severe consequences could include liver or kidney damage or even death (Naser & Al-shehri, 2023).
- Healthcare Team: Nurses, physicians, and pharmacists faced increased vigilance and self-reflection. The incident prompted immediate procedural checks and longer-term retraining in safety protocols.
- Organization: Hospitals face reputational risks and financial implications, including costs associated with incident investigation, staff retraining, and system improvements.
Accountability and Stakeholder Responsibilities
| Stakeholder | Accountability & Actions |
|---|---|
| Night Shift Nurse | Failed to verify MAR; requires retraining on medication safety protocols. |
| Day Shift Nurse | Correctly documented medication but must emphasize verification during handoffs. |
| Pharmacists | Review prescriptions to prevent duplication or errors. |
| Hospital | Ensure safety culture, implement technologies (BCMA, CDSS), maintain transparency, and provide staff training. |
| Interprofessional Team | Promote accurate communication, verification, and adherence to standardized protocols. |
To mitigate risks, the hospital should integrate advanced technologies, such as Barcode Medication Administration (BCMA) and Clinical Decision Support Systems (CDSS), alongside structured handoff protocols. Such measures ensure near-misses do not escalate into severe adverse events while maintaining patient and community trust.
Assumptions
This analysis assumes that the involved staff were trained in established medication administration protocols but human error contributed to the incident. It is also assumed that the hospital had some safety measures in place, though they were insufficient to prevent this near-miss. Transparency and effective communication during the resolution foster an environment where lessons learned can refine safety practices.
Root Cause Analysis of Medication Administration Error
The root cause analysis (RCA) identifies underlying factors contributing to the error and informs strategies for prevention (Miller, 2021). Key findings include:
- Handoff failure: Critical medication information was not communicated.
- Inadequate cross-checking: The MAR and prior doses were not verified.
- Limited utilization of available technologies: BCMA, CPOE, and EHR alerts were underutilized due to limited staff knowledge.
The primary cause was a breakdown in handoff procedures and insufficient verification. Implementation of standardized handoff protocols and enhanced use of technology would help prevent future errors (Stolic et al., 2022).
Knowledge Gaps and Areas of Uncertainty
The incident highlighted several knowledge gaps:
- Adherence to multi-step verification processes.
- Consistency in staff training and protocol application.
- Communication dynamics during handovers and use of structured tools.
- Impact of shift work stress on attention to detail and procedural compliance.
Addressing these gaps requires evaluation of technological integration, staff education, and system-level adjustments.
Evaluation of Quality Improvement Actions and Technologies
Quality improvement initiatives should integrate technology and procedural strategies to reduce medication administration errors. Technologies such as BCMA, CDSS with EHR alerts, and communication checklists reduce human error and improve adherence to protocols (He et al., 2022).
| QI Action/Technology | Purpose & Benefits |
|---|---|
| BCMA | Verifies patient and medication details at administration, preventing duplication. |
| CDSS with EHR Alerts | Provides real-time notifications for dose errors or conflicts. |
| Structured Handoff Protocols | Ensures accurate communication of critical medication information. |
| Staff Training & Simulation | Reinforces protocols, improves preparedness, and reduces human error. |
| Auditing & Feedback | Monitors adherence, identifies gaps, and informs continuous improvement. |
Success is measured through reduced medication error rates, improved patient outcomes, protocol adherence, and staff feedback (Pruitt et al., 2023; Wilson et al., 2022).
Quality Improvement (QI) Initiative
The QI initiative at Saint Mary Hospital aims to prevent future medication errors. The Plan-Do-Study-Act (PDSA) cycle supports structured implementation:
- Plan: Integrate BCMA, CDSS, and standardized handoff tools. Train staff in proper verification and labeling protocols (Ahn et al., 2021).
- Do: Audit the pediatric unit to detect process gaps and reinforce training.
- Study: Analyze audit results and staff feedback to evaluate effectiveness.
- Act: Adjust protocols, expand successful strategies to other units, and continuously improve safety practices (Isaacs et al., 2020).
This initiative aligns interprofessional teams toward consistent, safe medication administration while fostering a culture of accountability and transparency.
Conclusion
The near-miss involving an extra acetaminophen dose revealed significant gaps in communication, medication reconciliation, and verification processes. Implementing QI strategies such as BCMA, CDSS, structured handoffs, and continuous staff training can prevent future incidents. Utilizing the PDSA cycle ensures systematic evaluation and refinement of interventions. These measures enhance patient safety, rebuild trust with families, and improve overall healthcare quality at Saint Mary Hospital.
References
Ahn, J., Jang, H., & Son, Y. (2021). Critical care nurses’ communication challenges during handovers: A systematic review and qualitative meta‐synthesis. Journal of Nursing Management, 29(4), 5–32. https://doi.org/10.1111/jonm.13207
He, M., Huang, Q., Lu, H., Gu, Y., Hu, Y., & Zhang, X. (2022). Call for decision support for high-alert medication administration among pediatric nurses: Findings from a large, multicenter, cross-sectional survey in China. Frontiers in Pharmacology, 13, e2–e19. https://doi.org/10.3389/fphar.2022.860438
Isaacs, A. N., Ch’ng, K., Delhiwale, N., Taylor, K., Kent, B., & Raymond, A. (2020). Hospital medication errors: A cross-sectional study. International Journal for Quality in Health Care, 33(1), mzaa136. https://doi.org/10.1093/intqhc/mzaa136
Miller, K. (2021). Comparing the effects of traditional education and root-cause analysis on nursing students’ attitudes about safety culture and knowledge of safe medication administration practices. Nurse Educator, 47(3), 139–144. https://doi.org/10.1097/nne.0000000000001126
Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2020). Severe and fatal medication errors in hospitals: Findings from the Norwegian incident reporting system. European Journal of Hospital Pharmacy, 28(1), e56–e61. https://doi.org/10.1136/ejhpharm-2020-002298
NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis
Naser, A. Y., & Al-shehri, H. (2023). Paediatric hospitalisation related to medications administration errors of non-opioid analgesics, antipyretics and antirheumatics in England and Wales: A longitudinal ecological study. BMJ Open, 13(11), e080503. https://doi.org/10.1136/bmjopen-2023-080503
Pruitt, Z. M., Kazi, S., Weir, C., Taft, T., Busog, D.-N., Ratwani, R., & Hettinger, A. Z. (2023). A systematic review of quantitative methods for evaluating electronic medication administration record and bar-coded medication administration usability. Applied Clinical Informatics, 14(01), 185–198. https://doi.org/10.1055/s-0043-1761435
Stolic, S., Ng, L., & Sheridan, G. (2022). Electronic medication administration records and nursing administration of medications: An integrative review. Collegian, 30(1), 163–189. https://doi.org/10.1016/j.colegn.2022.06.005
NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis
Wilson, C., Howell, A.-M., Janes, G., & Benn, J. (2022). The role of feedback in emergency ambulance services: A qualitative interview study. BMC Health Services Research, 22(1), 296. https://doi.org/10.1186/s12913-022-07676-1