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

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

• Organization: The organization where the issue has occurred also has to face the impact of the action. Accidents in which heart patients receive the wrong medication can be extremely damaging to the organization’s reputation and can erode patients’ and the community’s trust in the medical facility. It is probable that as a result of this, the number of patients may decrease, along with a loss of revenue and severe legal obligations. The penalties, sanctions, or necessary corrective actions that regulatory bodies may impose may have a detrimental impact on the organization’s ability to maintain its financial stability and continue its operations. These penalties, sanctions, and necessary corrective activities may come in the form of fines, suspensions, or other requirements. Healthcare organizations will need to make investments in the process of examining drug practices, putting safety measures in place, educating personnel, and upgrading systems in order to reduce the likelihood of errors of a similar sort occurring in the future.
• Families and caregivers:This can be an emotionally challenging issue for caregivers and their families. They may also experience psychological stress and anxiety regarding the well-being of the patient, along with the difficulties of navigating medical care and finding the correct ways to ensure the patient’s well-being. This may also cause resentment and anger toward the healthcare system and the overall impression of the government in charge.
• Insurance and government: both of these parties have a financial burden due to the incorrect medication as the hospitalization time increases, causing more expense and leading to more use of resources.

Root Cause Analysis of the Wrong Medication

The root cause analysis of the situation that is being discussed is based on multiple perspectives, with the aim of finding every possible loophole that might have led to the medication error in a heart patient.

1. Prescription stage: The most significant error that might have occurred on the whole was associated with a wrong prescription, incomplete patient information, or the pharmacist’s inability to read the doctor’s prescription accurately. If the patient’s information is incomplete or missing, chances are that the prescription may be wrong as their entire history is not clearly seen.
2. Misinterpretation of Physician Writing: Many errors occur due to the inability to read the writing of the physician or typing the wrong spellings of the formula, which may change the entire class of medication that has been prescribed.
3. Misreading of the prescription: At times, the issue is associated with the pharmacist not being able to carefully pack the medication, thus leading to the medication error.
4. Administration stage: The fact that the nurses or the administration staff handed over the wrong medication may become a potential cause of concern for the patient.
5. Monitoring and follow-up stages: Lastly, the fact that the nurses or the healthcare providers failed to assess the efficacy of the medication in the monitoring or in the follow-up and continued a medication that was not beneficial for the patient

Quality Improvement Actions

The quality improvement actions allow the physicians as well as the nurses to become prepared for such issues and have a better plan to combat them in case of emergencies. Thus, to increase patient safety, the following plan can be implemented:

• Enhance Medication Safety: Patient safety is of paramount importance, so the first step in improving medication management is to streamline the medication administration process. This can be done, for example, by using a patient entry order that sorts medications alphabetically by their formula names rather than their brand names. Other methods could be using the barcodes or identifying specific medical dispensaries where people can buy those medications.
• Communication in Teams: Having a standardized handoff protocol would also help in establishing clear and guided communication and information exchange, which increases patient safety and the quality of care that is being provided. Similarly, promoting effective teamwork and communication among other healthcare providers, such as nurses, doctors, and pharmacists, can increase the safety of medication.
• Patient Engagement and Education: Another way to promote medication safety and improved healthcare is by engaging patients and edu