NURS FPX 6016 Assessment 1

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