NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis NURS-FPX 6016 Quality Improvement of Interprofessional Care ​​​​​​​Adverse Event or Near Miss Analysis

Comprehensive Analysis of Adverse Event

During my nursing practice, I witnessed when my fellow nurse, Amelia, committed a mistake that led to an adverse event. She also faced a financial penalty. Last week, Amelia was assigned to care for a patient named Jennifer. She was hospitalized in the Henry Ford Hospital due to suffering from Gastroenteritis. She was admitted to the hospital for the last three days. During our shift, Jennifer complained of gastric pain and feeling dizziness, and nausea. I asked Amelia to call the doctor, and he verbally prescribed and guided Amelia about the medication named Metoclopramide to Jennifer.

Due to the high workload and staffing shortage, Amelia was stressed. She, carelessly and without medication reconciliation, administered Metoprolol drug to Jennifer instead of Metoclopramide. Me and my colleague observed that Jenniffer’s health worsened due to the wrong drug administration. She has a rash allergy and has difficulty in breathing. Upon investigation, it is found that this ADE occurred due to Amelia’s mistake. Jennifer’s family was informed about this ADE and her condition. I witnessed this complex event that prompted the nurse manager and hospital management to investigate adverse medication events further in their hospital to ensure the safety of patients and Quality Improvement (QI). 

Implications of Adverse Event for Relevant Stakeholders

Adverse events in healthcare necessitate the planning, development, decision-making, financial support, and implementation of solutions by a multi-professional team and diverse stakeholders to ensure patient safety and QI. In Jennifer’s case, the Medication Administration Error (MAE), resulted in an ADE. It has several implications for particular stakeholders, such as the patient and her family, nurses, and management. In the Henry Ford Hospital, the adverse incident has a detrimental influence on Jennifer and her family. ADE has substantial emotional, economic, physical, and socio-behavioral effects on patients and significantly diminishes trust and readiness to accept healthcare (Prentice et al., 2020). Numerous medical interventions significantly altered the patient’s standard of life.

Jennifer’s family members faced emotional difficulty as they witnessed their loved one need further therapy due to ADE. They were dissatisfied with hospital administrators and caregivers who were unable to provide appropriate patient care. After the ADE, the nurse in charge of the unit experienced professional difficulty, negative emotional consequences, and legal action. Furthermore, the nursing staff stressed correcting gaps in patient safety protocols and preventing future tragedies (Mahat et al., 2022). Lastly, the hospital administration faced reactions from patients’ family members, resulting in a drop in reputation, lower patient volume, and monetary repercussions (Ozeke et al., 2019). 

Adverse patient outcomes entail consequences for medical professionals, hospital administrators, and legislators. Nurses and physicians are primarily responsible for providing quality treatment to their patients utilizing established clinical practices, particularly in terms of medication safety (Bello, 2021). Nurse leaders must ensure that each staff member has a thorough understanding of medication safety best practices. Furthermore, management and legislators must set regulations for safe medicine delivery that ensure patients’ safety is not compromised. Moreover, administrators should initiate educational and training sessions to make nurses aware and equip them with the abilities and skills to adhere to safe drug administration protocols (Park & Han, 2023).

Assumptions

This analysis assumes that patient health is the first concern for medical personnel, including nurses, and efficient procedures are required to ensure Jennifer’s safety (Prentice et al., 2020). It is assumed that medical staff, particularly nurses, provide high-quality care while protecting patient safety and fulfilling their ethical obligations. An expanding proportion of errors and adverse occurrences causes mental stress among healthcare personnel, resulting in additional issues for both patients and the health staff.  Negative outcomes and errors constitute a component of the medical system; however, stakeholders need to work together efficiently to reduce ADEs and enhance the standard of life (Mahat et al., 2022).