Analysis of Sequences of Events, Missed Steps, and Protocol Deviations NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

The missing steps and protocol variation encompass an absence of medicine administration protocols. The nurse did not observe the five rights of drug delivery. The nurse must be educated on the appropriate patient, drug, dosage, route, and time. Deviating from each of the rights can result in significant MAEs and negative consequences (Spanakis et al., 2020). Due to a lack of knowledge of drug administration protocol, my nurse fellow administered the wrong drug without considering the five rights of medicine, which ultimately resulted in ADE. Furthermore, lack of following the medication reconciliation technique. Medication safety recommendations were not adequately implemented, indicating insufficient training and compliance with standard protocols by medical staff (Park & Han, 2023).

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

One of the reasons for the medication error adverse event for Jennifer is that Amelia was in a hurry and she did not consider reconciling drugs and administered the wrong drug to Jennifer, leading to severe side effects. There was also a demand for improved communication routes between nurses and patients to facilitate timely responses to critical health requirements. Except in an emergency event, it is strictly prohibited to follow verbal prescriptions in medical settings. To avoid errors in drug prescription and delivery, the nurse should not follow the doctor’s verbal command. Paper-based drug prescriptions reduce drug errors and improve patient outcomes (Sendlhofer et al., 2019).

If the doctor has prescribed the medication in written form, it can aid my fellow Amelia in understanding the prescription better. Ultimately, it can avoid adverse events. Lastly, in the event of a staff shortage, the nurse should notify their supervisor so that such acts do not jeopardize the safety of the patients. By hiring more staff, the burden of nurses like Amelia can be reduced, and she can offer efficient care to patients by mitigating such events. Nurse managers should design regulations and procedures to deliver efficient care without compromising patient safety (Harton & Skemp, 2020). 

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

Although the analysis identified the leading causes of the adverse event, there are specific gaps in knowledge and areas of uncertainty that demand additional information for comprehensive analysis. More information is required to determine whether the patient, like Jennifer’s medical history, can give an understanding of their level of risk. Moreover, why was the doctor unaware of the policy regarding verbal prescriptions? Why did the nurse manager not manage the understaffed situation? What function did the administration perform in this situation? More information will make conducting a thorough and coordinated adverse event evaluation easier.

Quality Improvement Actions and Technologies

Several QI strategies and technologies are examined to be employed within Henry Ford Hospital to lower the likelihood of ADE caused by MAE. Strategies include adopting a comprehensive medication delivery protocol, providing medication safety education, and developing technological interventions. The incident happened because of a lack of safety protocol; a comprehensive medication administration protocol must be implemented.

It includes compliance with the five rights of drug delivery, double checking, and medication reconciliation guidelines must be established (Sharon et al., 2024). By providing adequate education to nurses, including Amelia, become aware of standard drug delivery guidelines. Conducting training sessions, including comprehension activities like simulation-based exercises, improves the capabilities of Amelia and other nursing staff. It will aid in avoiding such ADE in the future. Another QI practice advocated is to avoid verbal prescriptions. According to the research, verbal orders should be avoided wherever feasible and should only be used in extreme circumstances, such as an emergency. Every hospital, including Henry Ford Hospital, should create a policy to omit verbal prescriptions to maintain medication safety (Ambwani et al., 2019).

Moreover, medication safety training and education for nurses is a vital action for QI. Nursing personnel acquire knowledge and confidence in recognizing the circumstances in which MAE arises and applying theoretical knowledge in practice to fix them. High-fidelity models and problem-oriented instruction have a crucial impact on lowering ME and improving patient safety for Jennifer (Park & Han, 2023). 

NURS FPX 6016 Assessment 1 Adverse Event or Near-M