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

NURS-FPX 6016 Quality Improvement of Inter-professional Care

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Introduction 

In the medical field, medication management tends to be one of the most important parts of any procedure or treatment, and any significant error in the medication tends to become hazardous for the patient and leave a bad impression on the hospital. Medication errors continue to be one of the most significant adverse events in medical history. Researchers have deeply investigated the contributing factors that may have contributed to the medical error (EMA, 2018; Stolic et al., 2022). There has been a tremendous increase in the number of patient safety-related publications explaining how near-misses or adverse events have impacted or caused potential harm (World Health Organization, 2018).

Similarly, the World Health Organization has highlighted that one of the major causes of injury and avoidable harm in the health care system across the world is associated with medication errors, such as giving the wrong medication. Medication errors occur when inadequate medication systems and/or human factors such as weariness, bad environmental conditions, or staff shortages affect prescription, transcription, dispensing, administration, and monitoring practices (Khan & Tidman, 2022). These errors can then result in serious injury, disability, or even death. Implementing stronger medication systems and managing human factors can also prevent medication errors. Likewise, the estimated cost due to medication errors is approximately 42 billion dollars (World Health Organization, 2016).

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

The aim of the current assignment is to understand the impact of medication errors. The case under discussion was based on providing the wrong medication to a heart patient, which led to an emergency situation. Due to the error on the part of the nurse, the patient had to undergo surgery, which had a significant impact on the patient. The aim of the current analysis was to investigate the near-miss incident and the implication it had on all the stakeholders, the root cause analysis, and the action plan to combat the issue.

Implications of the Wrong Medication for All Stakeholders

It is critical to understand that the wrong medication can have serious consequences, especially in critical cases such as those involving heart patients. For example, when such medication errors occur on the patient if the health care provider is a heart patient, the consequences are severe due to the critical nature of cardiovascular health. Medication error is a long-term problem, as it may come with many consequences for all of the individuals that are directly or indirectly affected by it (Marufu,  et al., 2022). It can have an impact on many stakeholders, such as:

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

• Patients: One of the most commonly affected stakeholders when it comes to medication errors is the patient himself. As the medication is being implemented on the patient, the direct impact will be on the patient. Heart Patients are more susceptible to the negative effects that can arise from taking the incorrect medication. The inappropriate use of medication can have negative consequences for the cardiovascular system, which may result in arrhythmias, variations in blood pressure, reduced cardiac function, or other life-threatening issues. Patients could have chest pain, difficulty breathing, lightheadedness, or even cardiac arrest as a result of the condition. Taking the incorrect prescription might make the underlying cardiac problem worse, which could lead to permanent damage or even death in the long run. Patients may experience mental discomfort, dread, and a lack of trust in the healthcare system in addition to the physical effects of the condition.
• Healthcare provider: The next in line for the massive impact are the healthcare providers, who are technically responsible for the prescription-to-administration process of wrong medication that may have caused serious health hazards for the patient. The healthcare providers may have emotional and professional implications such as guilt, remorse, and a sense of incompetence that may impact their medical practice and affect their confidence. Also, it can lead to reputational damage, legal consequences, and disciplinary action that may result in scrutiny, the cancellation of a license, additional workload, and excessive training.