Analyzing Adverse Events and Near Misses in Nursing- A Case Study and Proposal for Quality Improvement Initiatives

An adverse event refers to an unwanted outcome that results from patient treatment. This event results from the treatment process rather than the patient’s underlying condition. A near-miss is a medical error with the potential to harm the patient but is addressed promptly, and no harm occurs (Vincent et al., 2018). Healthcare facilities should formulate strategies and policies to minimize the incidences of adverse events. This is important for the overall well-being of the patient and promotes self-satisfaction among healthcare providers. This paper provides an analysis of an adverse drug event. In addition, it provides the implications and strategies to mitigate adverse events. Hire our assignment writing services in case your assignment is devastating you.

A patient reported to the hospital’s orthopedic departments for his scheduled hip replacement surgery. The orthopedic surgeon pointed out that the patient should receive an extended-release morphine liposomal epidural injection before the surgery. He ordered 10 milligrams (mg) of liposomal morphine to be administered. The perioperative nurse administered 20 milliliters of a 10 mg per milliliter ampoule. This was about twenty times the prescribed dose. The patient suffered from difficulty in breathing, became cyanotic, and entered a comatose state. The antidote, naloxone, was out of stock at the time of overdose. An emergency acquisition was made from the neighboring facility. Intravenous administration of the antidote reversed the respiratory depression partially. The patient had to receive respiratory support for one week. The surgery was rescheduled.

Analysis of the Missed Steps Related to the Adverse Event

Adverse events frequently occur due to an improper framework of health care operations. However, most of these adverse events are not reported. Patients usually experience prolonged stays at the hospital managing adverse events rather than their presenting complaint. A regular departmental audit can help to identify the occurrence of adverse events and put in place mitigative strategies.

In this context, protocol deviations and missed steps significantly contributed to the adverse events. The morphine ampoules present in the medication tray had a strength of 10 mg per milliliter. Each ampoule had a capacity of 20 milliliters. Therefore, each ampoule contained a total of 200 mg of morphine. The nurse did not countercheck the strength of each ampoule. The package label of 10 mg per ml made her assume that the ampoule contained a cumulative dosage of 10 mg. She ought to have confirmed the calculation with her colleagues or brainstormed with the surgeon before administering the medication. Furthermore, morphine is a potent opioid analgesic, and a thorough review should be taken before it is administered.

The nurse and the prescriber should have checked for the presence of an antidote before administering morphine. Owing to its potency, morphine overdose is associated with life-threatening adverse events. Notably, morphine causes respiratory depression. This is caused by the inhibition of the neurokinin-1 receptors in the brain (Kiyatkin, 2019). The ensuing hypoventilation due to reduced oxygen supply to body tissues causes cyanosis. This progresses to coma and death if not managed promptly. The absence of naloxone before the operation is a risk. It demonstrates poor planning. Furthermore, it may indicate a lack of awareness of the importance of the antidote.

This adverse event was preventable. The nurse should have crosschecked her calculations and re-read the labeling of the ampoules to determine the capacity. This would have ensured that an accurate volume of the drug is withdrawn. Furthermore, she would have consulted her colleagues to ensure that the correct quantity was being administered. The absence of naloxone should have prompted consultations with the hospital pharmacy and the administration to acquire the important drug. Therefore, deficiency in communication, collaboration, and analytic skills caused the adverse event.

Morphine and other opioid overdose is a concern in other facilities globally. Studies done in 2019 revealed that approximately 500,000 people lost their lives due to substance abuse (Centers for Disease Control and Prevention, 2019). About 30 percent of the lives were lost due to overdose. More than 100,000 succumbed to opioid overdose, especially heroin, fentanyl, and morphine (Centers for Disease Control and Prevention, 2019). Therefore, morphine overdose is an adverse event of concern.

Implications of Adverse Event on Stakeholders

The adverse event affected all of the stakeholders involved. The patient and his family were impacted acutely and in the long term. The patient suffered from