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

Adverse Event or Near-Miss Analysis

The capacity to find and examine cases where patient safety is compromised is an important responsibility of the healthcare organization. The systematic analysis of near-miss incidents and unsuccessful events assists those working in the medical sphere to determine the weak points of the clinical working process, communication patterns, and technological structures.

By withholding appropriate assessment, organizations will be in a position to comprehend the cause of the problem, analyse the impact or the impact on the patients and stakeholders, and adjust certain quality improvement approaches. A near-miss medication error case will be discussed, and the emphasis will be placed on the fact that structured assessment and evidence-based interventions may be utilized to increase patient safety and minimize the risk of it happening again.

• Case Scenario

On one occasion, an incident of a near-miss medication occurrence happened in a mid-sized acute care hospital in the case of a high-alert intravenous anticoagulant infusion. During the regular shift, one of the bedside nurses complained that the infusion pump alarm had been intermittently activated, but appeared to shut off with no noticeable problem. The high workload of patients did not also raise the alarm to the on-call physician or pharmacy department, as there was no acute clinical degradation required.

It was later discovered during a routine review and check-up of the chart several hours later that the infusion rate had been entered in the wrong programming, and this exposed the patient to a high risk of hemorrhagic complications. Although no harm to a patient was observed, the event demonstrated major communication and process-level breakdowns that would have been examined and fixed on a system level.

Impact and Analysis of Adverse Events

Implications of this near-miss incident will be analyzed with respect to the effects of the same on different stakeholders. The patient was put at a near-death and potentially fatal risk of receiving inappropriate doses of anticoagulant, which could result in internal bleeding, a prolonged hospital stay, or a chronic complication (Ballestri et al., 2022).

Since there is no physical damage, the psychological impacts on the patient, like anxiety and lack of trust in the health care providers, cannot be overlooked. The family members may also be distressed when they are informed that something that could have been prevented has nearly occurred, and this may influence their confidence in the health care system.

This increased stress and urgency in the interprofessional care team at the time of the near-miss discovery. Doctors, nurses, and pharmacists were forced to rethink the communication workflow structure and accountability and identify the areas of failure (White et al., 2025).

At the organizational level, the facility became more susceptible to leadership and quality assurance committees, internal audits, and reviews of medication safety policy were launched (Zisu et al., 2023). The reputational risks and regulatory implications potentially create further importance to the task of addressing the systemic vulnerabilities. When done in a wise manner, these incidents can influence the behaviour of reporting over time to enhance more transparency and maintain a safety culture.

• Responsibilities

The issue of professional responsibility is a significant issue that must be well spelled out to prevent near misses with medication. In the case under consideration, the responsibility of the nurse was to report the alarm on the infusion pump that was not addressed right away to the prescribing team and pharmacy, and be able to intervene.

The physician was to check the medication order and alter the therapy when the necessity appeared, and the pharmacy staff played a significant role in checking the infusion parameters and prescribing the correct dose (Berry et al., 2024). The cooperation between these professionals is what is needed to ensure patient safety and quality care.

• Preventive Measures

The incident has seen the facility implement several preventative measures in order to curb the risk in the future. Standardized procedure was enhanced to ensure that any infusion pump alarm must be reported and added to escalation in case it is not handled. Mandatory educational activities concerning alarm management, medication safety, and interprofessional communication were implemented to ensure greater awareness and competence (Alhur et al., 2024).

Another type of advanced technology that was implemented in the hospital was the infusion pumps with inbuilt safety alerts, and real time update to staff members. All these measures contributed to transforming the practice aspects into more responsible, urgent, and active risk management, developing a culture of continuous improvement.

• Assumptions

In this analysis, communication failures and strains in the workflow are supposed to be relevant variables that caused the near-miss incident. Another assumption made is that the existing protocols were not reinforced or followed to a large extent, which did not allow them to be utilized in avoiding escalation failures.

The improvement of team communication, alignment of alarm response procedures, and technology are therefore considered to be essential towards reducing the risk in the future (Agius et al., 2025). These assumptions highlight the need to make system-wide interventions rather than lay the blame on individuals, and that patient safety is a universally shared responsibility.

• Root Cause Analysis of Adverse Events

When the root cause was analyzed, it was found that there were a number of steps that were omitted, and this contributed to the near-miss medication error. The alarm of the infusion pump reported the presence of a dosing issue, but there were no acute clinical symptoms, which resulted in a lag in the worsening.

The fact that they did not notify the physician and pharmacy, and the alarm had a poor record, was a significant breach of the set medication safety steps (Aradhya et al., 2023). These kinds of lapses allowed the infusion rate to persist longer than necessary, exposing the patient to danger. The findings indicate that the standards of escalation and documentation should be followed as they are rigorous to prevent such incidents.

• Inter-professional Communication

Inter-professional communication plays an important role in preventing near-miss medication and patient safety. In this instance, the failure to report to the physician and the pharmacy crew on unresolved alarms of infusion pumps promptly became a major threat to patients. Delayed escalation may have included heavy workloads and conflicting clinical priorities, but it does not exclude the necessity to exchange information on time (Hong et al., 2023).

The priority on the significance of alarms and escape routes must always be imposed in every sector. Improving communication behaviors will assist in the acceleration of clinical decision-making and eliminate the possibility of preventable errors.

Improved inter-professional communication requires systems that are organized and, as such, promote accountability and collaboration among the healthcare providers. They should adopt communication protocols that are standardized and have information-sharing platforms and closed-loop communication to ensure that urgent information is received and taken cognizance of within the shortest time possible (Hong et al., 2023).

Frequent interdisciplinary training and simulation help to develop good communication behaviour during high-risk situations, too. The active and transparent interactions between nurses, physicians, and pharmacists will be useful to reduce the potential safety risk and prevent its impact on the patient. These are measures that instill a culture of safety and collective responsibility amongst institutions of healthcare.

• Knowledge Gaps

It has been established in this discussion that some gaps in knowledge exist, and they will have to be bridged by carrying out further research to improve patient safety initiatives. It is observed that compliance of the staff with the protocol of alarm escalation and regularity of the training is limited in relation to the infusion pump management. In addition, the impact of huge workloads on the clinical judgment of patients, as well as the degree of effective communication, is poorly understood (Mahmoud et al., 2023).

The rate of conducting the review and using alarm-related incidents as learning points within the organization should become clearer. The system would become more responsive with the process of filling these gaps through special education, data gathering, and continuous assessment, and would reduce the possibility of such a near-miss association in the future.

Quality Improvements for Risk Reduction

The use of technology, communication systems, and the clinical processes involved in improving patient safety outcomes are supposed to be reviewed regularly. After the close call medication incident, the healthcare business came to the realization that it needed to strengthen its human and system-based quality improvement model.

Response to alarms being late and communication failures assisted in identifying the existing weaknesses of current workflows, making patients more vulnerable (Pruitt et al., 2023). The organization was active regarding quality improvement in order to reduce the preventable medication errors and enhance the quality of overall care. These programs emphasize the importance of the integration of safety-related policies into everyday clinical practice.

• Technological Safety Integration

The most significant quality improvement measures included the technological modernization of infusion pumps and the smart functionality, as well as the dose-error alarm. These can be used in conjunction with the electronic health record to create an automated alert to all nurses, physicians, and pharmacists simultaneously in deviation cases (Pruitt et al., 2023).

This integration has favoured both clinical intervention on time and a decrease in the use of manual escalation procedures. These technologies have been shown to significantly reduce medication-related errors as they increase care team accountability and visibility. The correct design and continuous observation of these systems should be required to keep them effective in the long-run.

The effective exploitation of these technologies through comprehensive training and education of the staff cannot be disregarded either. To make the perception of the alarm, understand the principle of escalation, and respond effectively to the high-risk situation, medical workers are to be offered the required training (Pruitt et al., 2023).

The best practices are further supported by regular testing of competency and training that are done in simulation and in refreshing courses that make sure that there is similarity of response to the various disciplines. It is also effective to increase the continuous training to decrease the effects of alarm fatigue by increasing the confidence of the staff so that they know which alerts are critical and the alerts that are not urgent. The behaviours strengthen clinical judgment and patient safety outcome enhancement.

• Quality Improvement Benchmarking

The quality was also improved with the help of comparisons with the practices that are followed in other healthcare institutions. The majority of these successful organizations have adopted the concepts of using standardized alarm management practices and interdisciplinary response teams to address the medical-related alerts. Another discovery made is that the integration of clinical dashboards and real-time reporting systems could improve the response time and rate of near-misses (Hussin et al., 2025).

Benchmarking process also enabled the facility to identify areas of weakness and areas of improvement by comparing the facility’s performance with what is available outside. It is also decision-making and continual optimization of systems, which is promoted through the application of tried and tested strategies in other institutions.

The quality improvement efforts are quantified by monitoring the performance indicators of concern. The key indicators, with the help of which the intervention effectiveness can be measured, are the protocol adherence, the near-miss medication events, patient outcomes, and alarm response times (Hussin et al., 2025).

Patient satisfaction and readmission trends are other areas that can be identified as influenced by the effect of improved safety. The common scrutiny of these metrics enables timely change and ensures that the organization is charged in the correct direction with respect to safety. Continuous assessment and improvement on the basis of data can ensure that healthcare organizations are able to sustain high risk reduction and enhance patient safety.

• Evaluation Criteria

The alarm response times, number of near-miss medication events, adherence to the escalation protocol, and patient safety outcomes are key performance indicators that are used to measure the effectiveness of quality improvement efforts. The information about the overall impact of implemented interventions can be provided with other indicators, including patient satisfaction rates and readmission rates (Slavinska et al., 2024).

The comparison of the trends in the internal data with the external rates will allow the organization to measure its advancement and reveal the aspects of improvement. Patient safety practices can be improved in the long term by addressing these criteria regularly to facilitate evidence-based decision-making.

• QI Initiative

The alarm management and interprofessional communication weaknesses propelling the near-miss medication incident have resulted in the creation of a systematic quality improvement program (Slavinska et al., 2024). The hospital adopted the Plan-Do-Study-Act (PDSA) model to organise these vulnerabilities, focusing on technology and workflow solutions.

Monitoring the infusion pump systems in real time and integration of the alerts into the electronic health record have been the key factors to ensure that the right team members receive relevant notifications within the appropriate time.

Standard communication standards were brought to explicitly define the procedure of alarm escalation, which cannot be solved. The adoption of such protocols was supported by interdisciplinary training and simulation activities that made sure that the personnel were conversant with the main protocols, which necessitated prompt reporting, documentation, and problem-solving among themselves (Slavinska et al., 2024).

The compliance is to be checked, and the time of the alarm response is to be measured, and develop accountability among nurses, physicians, and pharmacists, which is planned to be introduced with regular audits.

Evidence-based practices that include smart infusion pumps, secure messaging, and structured communication devices have been proven to reduce medication errors through developing proactive responses and minimizing human error (Zheng et al., 2020).

The sustainability will be ensured through continuously assessing performance markers and continuously educating the employees, which will foster a culture of safety and ensure the changes that have been made will be sustained. All these measures are aimed at making sure that such near-miss incidents are avoided in the future, therefore, making the work of the patients safer on the whole.

• Conflicting Perspectives

Even though most of the stakeholders support the fact that management of alarms is improved and organized communication standards are implemented, some of the stakeholders express concerns regarding the likelihood of the workload and the likelihood of alarm fatigue.

In order to achieve safety and efficiency equilibrium, the staff must be engaged in planning the interventions and applying them, and make sure that their views affect the adjustments to the workflow (Zheng et al., 2020). The resistance could be managed through the assistance of specific training and the active involvement of the stakeholders, which will enhance compliance. Being able to think through divergent views helps to open up and be cooperative, which is paramount to a quality improvement endeavor in the long run.

Conclusion

The importance of alarm management, proper communication, and safety measures is introduced through the near-miss medication incident. Short-term solutions include the training of the personnel, technological level development, and the standardization of the procedure of escalation, which address the most significant vulnerabilities.

The recurrence may be avoided in the long-term plans that presuppose the continuous monitoring and safety culture promotion. The evidence-based improvements can enhance patient safety, quality of care, and trust of the stakeholders and offer long-term effectiveness.

Related Free Assessment for NURS-FPX6016

NURS FPX 6016 Assessment 2

NURS FPX 6016 Assessment 3

Need help with NURS FPX 6016 Assessment 1? Get expert solutions from Tutors Academy and improve your scores today!