Student name 

Capella University

NURS-FPX6016 Quality Improvement of Interprofessional Care

Professor’s Name

Submission Date

Adverse Event or Near-Miss Analysis

Although safety is a priority in healthcare settings and advances in technology, systems, and training have been instituted, adverse events and near misses have not been eliminated. Errors in medication are the most prevalent type of avoidable harm and can occur at multiple points in the medication process, from the prescribing through to the drug administration (Tariq et al., 2024). Analysis of these events can identify significant and constructive systemic weaknesses and challenges to quality improvement (QI). This review focuses on a near miss of an insulin administration event in American hospitals and considers the impact of this on the stakeholders, performs a root cause analysis and considers QI and associated technology, and proposes an evidence-based QI initiative to prevent similar events.

• Case Scenario

St. Mary’s Medical Center almost experienced a serious incident with Mr. Robert Hall, a post-operative diabetic patient who had a knee replacement. During a busy day, the night nurse verbally told the patient (during the blood glucose reading) to give a target blood glucose reading of 410 mg/dL (instead of the correct 140 mg/dL). The day nurse was going to give the patient 20 units of insulin (instead of the correct 4 units). While this was happening, one of the student nurses was going through the patient’s electronic health record and was able to intervene and verify the order before it was administered. In line with the most recent literature, the incident was a close call with no patient harm, as it gave the health care system an opportunity to realize some of the vulnerabilities that exist in the system regarding handoff communication, compliance with the protocols, and verification, as well as the gaps that exist in the current system to address high-alert medication errors. The introduction of technology in a more structured, facilitated, and integrated manner would help establish double checks in the system that could strengthen patient safety.

Impact and Analysis of Near Miss

The near-miss incident involving insulin at St. Mary’s Medical Center impacts a wide range of stakeholders. The immediate effects on Mr. Hall, the patient involved, included the potential for hypoglycemia and the development of anxiety, while he may experience longer-term effects of developing a mistrust of the entire healthcare system and of the safety of his prescribed medications. The patient’s family became increasingly more vigilant and active in the patient’s care. The interprofessional team became aware of deficiencies in their communication and in their checking of and adherence to procedures, as well as in the handoff of care. This undoubtedly resulted in a great deal of thought and reflection as to the issues surrounding handoff of care and the medical teams’ responsibility. Haliq and AlShammari. (2025) cited significant communication issues when a paramedic and a nurse complete a handover in emergency medical care. The organization also has the potential to lose its business, and its safety culture becomes not only a priority but a necessity. The case illustrates that every healthcare organization should invest in safer systems that minimize the risk of medication errors and safeguard their patients.

• Responsibilities

The nursing, medical, pharmaceutical, and clinical teaching professions all have responsibilities in avoiding these incidents. The collaborative practice teams have been the best in delivering person-centered care and in improving the outcomes of the patients and the system (McLaney et al., 2022). It is the role of the nurse to carry out an assessment and report, as well as conduct a drug check for the high-risk medications. It is the role of the doctor to order and report for the patient. The pharmacist is responsible for checking the dose and for the safety alert. It is a requirement for all the team members to avoid injury to the patient by collaborating and communicating effectively and efficiently during handoffs and while reporting abnormalities.

• Preventive Measures

The prevention of errors during the handoff of high-risk medications from one healthcare professional to another requires the use of SBAR as well as the two-check approach. The use of the electronic health record system with the dose alert differentiations also serves as a prevention measure. It has been proven that the use of SBAR and mind mapping reduces the occurrence of errors and adverse events and boosts satisfaction in nursing (Haliq and AlShammari, 2025). There is an imperative need to create educational programs focused on the safe administration of insulin and the management of fatigue, as well as interprofessional communication. The management of the nursing unit and the quality improvement committee are tasked with the responsibility of creating policies, enhancing compliance, and evaluating the reporting of near-misses to improve practices focused on patient safety.

• Assumptions

In this analysis, we assume that personnel have clinical competencies, but issues related to high-volume workloads, environmental challenges, and inconsistent handoff procedures created barriers. It assumes that the nursing student was the first and only line of defense to recognize and capture the near miss, and that it was not the result of an automated system fail-safe. Errors and near misses predominantly occurred as students failed to check for patient identification and allergy status, and apply the rights of medication administration (Silvestre & Spector, 2023). Blame for the near misses and errors is placed on the system, and not the individual staff. It is assumed the incident will result in practice changes for the staff that will incorporate additional verification, enhanced documentation, and stricter adherence to interprofessional communication standards.

Root Cause Analysis of the Sequence of Events

The incident at St. Mary Medical Center reveals a much larger failure of the medical system as a whole, rather than being the simple case of a patient with diabetes. The blood glucose level of Mr. The was at a normal level of 140 mg/dl. This incident was triggered by a series of events that began with a verbal handoff during the start of a busy morning shift when the nurse from the night shift falsely reported a blood glucose level of 410 mg/dL. Based on that faulty information, the day nurse would have administered a dangerously incorrect dose of insulin. Silvestre and Spector (2023) have reported that since a near-miss incident is the result of negligence by a nurse and is not attributable to policies and procedures, the student nurse who reviewed the electronic health record (EHR) and noticed the discrepancy prior to the administration of the insulin was the safeguard that ensured the patient was not harmed.

• Missed Steps and Protocol Deviations

Some procedures were bypassed, and this contributed to the incident. The EHR and charted blood glucose levels from the night nurse were not verified. The day nurse did not check the glucose level in the patient before preparing the insulin. Two-person checks and other communication tools, such as SBAR, were not utilized. Medication error contributing factors need to be identified to practice and improve safety (Rashdan et al., 2025). Contributing factors included environmental distractions, a heavy workload, and verbal communication as opposed to electronic communication.

• Preventive Interprofessional Communications

The incident would have never occurred if interprofessional communication had been done properly. Insulin would have been correctly dosed if communication tools, a read back of the value, and a check by the pharmacist, were used. Structured communication tools, especially SBAR, have been shown to improve the knowledge and understanding nurses have regarding shift communication in noncritical care areas (Haliq and AlShammari, 2025). Regular discussions at a shift change with an explicit statement of differences would minimize reliance on memory. Errors should be identified by all the professionals in the care team before the medication is administered.

• Preventability and Knowledge Gaps

This incident should not have occurred, and it enhances the need for improvement in safety procedures using technology. Some staff do not comply with the handoff and double-check procedures. There is a lack of understanding of how their workload impacts the accuracy of their work. There are also some gaps in understanding the obstacles to the near-miss reporting system. The Joint Commission states that 80% of adverse events or near misses are due to miscommunication during a handoff (Reime et al., 2024). It remains unknown if the same underreported near miss also has a lack of compliance and unreported staff adherence to the high alert medication policy. This indicates the need for further training and education, a review of the procedures in the system, and a restructuring of the system.

Quality Improvements for Risk Reduction

In order to boost patient safety and reduce the risks involved in insulin delivery, a number of improvements in quality (QI) and technology solutions can be introduced. Safety perceptions of anaesthetists and potentially the rate of medication administration errors among nurses, due to the introduction of barcode medication administration (BCMA), have decreased by 54% (Grailey et al., 2023). In the control of diabetes and the management of inpatient hyperglycemia, the integration of clinical decision support (CDS) in the EHRs has also positively influenced patient care (Gerwer et al., 2022). Considerable positive changes in the quality of the handoff communication have been reported with the introduction of the SBAR (Situation, Background, Assessment, Recommendation) model (Haliq & AlShammari, 2025). To improve the collaboration of medical staff, a communication model has been proposed (Jung & Park, 2025). The near miss and medication error rate per patient day, compliance with the double-check rule, and the duration of the response to the error are the indicators of the model’s effectiveness.

• Integration of Solutions in Other Institutions

Similar solutions have been implemented in other American institutions as well. For example, John Hopkins Hospital found that with the help of the smart agent system, nursing staff made 20 errors (16.6%) and delivered insulin in less time than the manual dosing calculation (John Hopkins Medicine, 2021). The Mayo Clinic uses structured EHR data to record lab results and medication administration records to help document the compliance of chronic disease management with evidence-based practice (Ramar et al., 2025). These solutions focus on system-level changes rather than individual changes and demonstrate patient safety enhancements that are measurable.

• Relevant Metrics Supporting Improvement

Hospital pharmacists have repeatedly reported the same errors to the relevant authorities. These errors increase patients’ suffering and have the potential to cause the avoidable death of patients. Literature from across the globe has identified that between one in every 1,000 and one in every 20 patients are adversely impacted by the omission and commission of errors internationally, 25% of which are serious or even fatal. Reporting of checklist-related ‘near miss’ and actual events, along with the degree of compliance, provides critical information for planning. The ‘near miss’ event at St. Mary’s Medical Center should serve as an opportunity to proactively address the reality that substantial system deficiencies should be remedied by the expenditure of significant resources on system and technology-based changes to prevent the ‘near miss’ from occurring again. The Quality Improvement Initiative to Avert Future Near Misses aims to address the ‘near miss’ of the administration of insulin at St Mary’s Medical Center, and to emphasize the necessity of a thorough, well-documented, evidence-based, continuous improvement approach to increase the safety of the management of high-risk medications.

Quality Improvement Initiative to Prevent Future Near Misses

The insulin near-miss incident at St. Mary Medical Center illustrates why a substantive, evidence-based Quality Improvement (QI) Program aimed at managing high-risk medications is warranted. The error in this instance was caught during the event, as the patient was simultaneously checked at a Blood Glucose Level in the Electronic Health Record (EHR) and administered insulin. The event was documented in the event reporting system, and the interprofessional group was debriefed. The debriefing is an inherent part of the medical simulation, and the benefits of the practice have been established within the instructional design (Salik and Paige, 2021). The focus of the continuous monitoring was placed on the near-miss reports, as well as adherence to the handoff procedure and the two-check rule. There is a large body of research that supports the use of a variety of different interventions to help prevent mistakes related to insulin, such as the use of BCMA, SBAR, order verification, and the use of simulation/labs to assist in the training of staff. The rationale for the use of these interventions is that they help to standardize practices, minimize memory reliance, and maximize opportunities for mistakes to be caught prior to harm. The interventions at St. Mary Medical Center would be the implementation of BCMA for insulin, SBAR for the handoff, the use of simulation for staff training, and the monitoring of near-miss reporting.

• Conflicting Perspectives

Although most studies support the effectiveness of both BCMA and structured handoffs, some studies show the adoption of both with technical issues and the disruption of established workflows. Clinicians constitute the final user group for EHRs, yet the EHRs present multiple obstacles that the system cannot even overcome for the clinicians to do their work and to better serve the goal of enhancing the overall patient care (Tsai et al., 2020). These barriers can be removed by means of staff participation, user training, and adjusting the workflows. Taking into account these barriers should promote the required combination of the best available evidence with the real world to increase the effectiveness of the system. This would promote staff participation and patient safety with the provision for ongoing advancement and eliminate the potential for the unintended negative consequences of the system.

Conclusion

The insulin near miss at St. Mary’s Medical Center demonstrates the need for effective rule-based communication and system-level trust defensive safety mechanisms. The gaps were identified during the root cause analysis, and multiple verification handoffs and communication were gaps in a QI interventional order. Trust in defensive safety mechanisms in systems is supplemented and/or sustained by the inputs of the stakeholders. This near miss illustrates a need to be engaged, and for a diverse and integrated approach to information technology to reduce adverse events and enhance the safety culture in the healthcare systems.