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

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

Adverse Event or Near-Miss Analysis
Madical arrora on part of the healtheare providers due to lack of attantion result in adverse avanta or near-miss aventa. These events
are preventable errors that can be minimized by providing healthcare providers with additional help through the Introduction of
tachnological ald.

Implications of an Adverse Event

An advarse occurred In the healtheare astup whara I work which resulted In fatalltles. The adverse event was due to a medlcation error
on part of the prescriber who had mistakenly administared a drug that led to an Instant decreasa In blood pressure and the patlent
underwant savare hypotenalve erises which Induced a coma In the patlent.

Thia advarse avant hurt the staksholdars (patlents and the hoapltar). Following this Incldent, many the number off patlanta who cama
to recelve healthoare services decreased drastically. The hospltal began to lose Its financlal, soclal, and aconomle standing as more of
Ita patlenta siarted to get healthoare services from other hoapltals.

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

Short-term and Long-term effects for Stakeholders

The short effact la that the patlent will be unsatlaffed, thay will be cautlous of the care that they will racelve at the hospltal and the
healtheare providers will be demorallzed by thelr Inabllity to prevant the medication eror that andangared the patlent’a Iife. The long-
tarm affect will be the lack of patlenta willing to reguire healtheare services from the hoapltal. In the healtheare system, the Investora
and owners will go bankrupt and will lose thelr businesa as the patlent would not ragulre healtheare sarvices from It.

Assumptions
The analysla la based on the assumption that the healtheare providara due to belng overburdaned make madical arrora that laad to
fatalitles, mortallty, and morbidity rate. As a result, patient dlssatsfaction Incraases and patlents refuse to racelve treatment from the
same hoapltal.

The sequence of Events/ Missed Steps
The saguence of events that led to the advarse event Involved the lack of abllity of the healtheare providars to evaluate and assess the
effect of the druga which were to be administared to the patlenta. The cardlologist came, assessed the patlent’s emergency condition,
and prescribed the druga that needed to be administered. The cardiologlat was In a hurry and needed to attend to othar patlenta, dua
to which he prescribed the wrong medieatlon (mlased step 1). The nursea were Instructed to follow the prescripton and since they did
not have anough knowledge to guestion the drug preseribed, they blindly adminstered the patlant with medication (mlased step 2).

The mediclna which was administered was Sodlum Nitroprusaide which Instantly decreased the patlent’a blood pressure and Induced
a coma. The patlent already hed low blood prassura and nesded traatmant for It, Instead of prescribing Atroplna, the cardiologlst
prescribed Sodlum Nitroprusslde which Is administered in case of sevare high blood pressure. The patlent was shifted to ICU
(Intenslve Care Lnit) to nullity the effact of the drug.

The above-mantloned missed stepa were responalble for the adverse avant which occurred. The factor which contributed to the
advarse avant waa the overburdan of the healtheara providera which resulted In a lack of time management of the healtheare
providara. The lack of managament resulted In the wrong prescription of the drugs which led to advarse eventa and andangared the
patient’s Ilfe.

Knowledge Gaps
Another missed step was the lack of knowledge of nurses ragarding the medication which are prescribed. They do not know the
pharmacologloal and pharmacodynamlc effecta of the medicationa and adminlater them to the patlent. As a result, adverse evana
occur which andanger the Iife of the patlent.

Quality Improvement Actions or Technologies
Quallty Improvement (0) actiona ara needed to prevent advarse avants and near-mlan avanta which endanger the patlent’a IIfe. The Ql
tachnologles which can be Implemented to raduce adverse aventa Include the Implamantatlon of an Electronic Health Record (EHR)
system. Along with thla, the Q action which can be Implemanted in the healtheare centar to reduce the chances of adverse aventa and
medication errors Includa the aducation of healtheare providers especlally the nurses about the druga (Holmgren at al, 2020).

Thla knowledge will help the nurses to be profielent to an extent that when medicationa ara prescribed the nurses can analyze, assess
and avaluate If the drug p