Adverse Event or Near Miss Analysis

Running head: ADVERSE EVENT OR NEAR MISS ANALYSIS
ADVERSE EVENT OR NEAR MISS ANALYSIS
Name of Student
Name of University
Author note

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ADVERSE EVENT OR NEAR MISS ANALYSIS
As a registered nurse working in the high paced clinical scenario such as intensive
care unit where the use and application of the imperative nursing strategies and the nursing
care plan is challenged with the need for ethical considerations and the legal considerations at
every point of time. I, as a registered nurse was posted in an intensive care unit during my
initial days of care and was attending a patient whose name was Charles, 66 years old and
was a patient who was receiving care in the hospital, following a cerebrovascular accident.
He was in a state of delirium when he was admitted in the hospital and due to the recurrent
episodes of loss of consciousness due to the underlying pathology and due to the effect of
medications as well – I did not have an opportunity to communicate with the patient properly.
He was from an African American community, elderly male with strong facial features but
masked expression and it was difficult to understand his feelings and ongoing thoughts
through a nursing observation. I lacked the required cultural competence skills and he was
being prescribed medications – to maintain the muscle tone and to maintain the high blood
pressure of the patient and as the patient had a history of heart congestion that is myocardial
infraction; he was given medication pertaining to the same as well (Peddie et al., 2018).
Hence, it is important to note that as I was a new graduate nurse who lacked both knowledge
and experience, I found my role of administering all the drugs on time to the patient very
difficult indeed. The fact that I was new to the clinical day to day nursing care, it was very
stressful for me to carry out my nursing duties properly and on one instance, I gave the
medication to the patient after supper following which the patient became pale and started to
have breathing issues. I checked the vitals which were bit high and the subject was struggling
to talk due to breathing issue. On calling my supervisor nurse, she rushed in and checked with
the patient and found out that I have made a medication administration error due to the
confusion with the names of medications which were almost same. This led to the
presentation of the adverse drug event, deteriorating the patient’s clinical condition and

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assisting my supervisor nurse, we somehow bought the clinical care into control and
management. Any severe clinical outcome was finally avoided.
I identified following the event that due to my lack of cultural competence, I never
communicated with the patient properly and educating the patient about the medications and
its effects on his health could have prevented this adverse drug event due to lack of effective,
ethical, patient centered medical and nursing management. I did not let the other experienced
nurses in the ward to have a ‘second check’ and lack of peer support are the factors that are
also responsible for the presentation of this adverse incident. I did not follow the evidence
based clinical flow guidelines in order to understand and guide the medication administration
in a safe and secure manner (Lee et al., 2017). There was no support from the electronic
reminders either that could have prevented this adverse medication administration event as
we were not trained to follow the instructions on the electronic boards to assist the clinical
medication administration. There was also a lack of psychological and clinical support from
the nursing supervisor that decreased my confidence, added to my stress and anxiety which
were also the reasons that led to the adverse drug event. It is critical to note that all the above
mentioned factors and reasons are very much preventable and a proper quality change in the
organization can address the health care change needs. In the other departments as well, the
new graduate nurses are facing the same problems with the clinical decision making and
medication administration errors due to the lack of psychological safety and increased
workplace disruption.
An adverse drug event can lead to decrease in health safety of the patient, decrease in
quality of care (delivered and received) for all stakeholders such as the clinicians and the
patients. It can lead to dissatisfaction in the patient and the family of the patient. The short
terms effects are health safety and poor prognosis and long term effects are diminishing of
organizational image and increased morbidity- mortality rates.

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It is critical to understand that the interdisciplinary team including the team of doctors
and surgeons from different disciplines, nurses, allied health practioners along with the health
care assistants can play a huge role in the quality improvement of the health care
organization. A proper a peer support and supervisor support system should at first be
developed as an integral part of quality improvement process in order to address the
psychological and social safety needs of the new graduate nurses (Banda et al., 2016). The
staff training and the skill development sessions of not only the new graduate nurses but also
of all the new staffs across various disciplines should be given to develop the understanding
and knowledge of health information technology use in the delivery of a more safe and secure
care process. Seminars and workshops to increase the health and disease related knowledge
of the nurses is a very important aspect of quality improvement and change in the health care
organization. In addition, the workshops and the skill development sessions on cultural
communication and language needs are very critical and quality improvement protocols has
to be concerned with cultural competence and cultural awareness knowledge needs of the
new nurses as well so that they can manage a wide range of culturally diverse patients as
well. The quality improvement and change process should take into consideration, the
behavioral patterns of the new graduate nurse who suffer more from social anxiety, burnout
and lack of psychological safety that is critical to the development of adverse medication or
drug event situation. Counseling sessions, relaxation therapies in order to teach and develop
the self-management skills and emotional intelligence skills in the new nurses must be an
important area of healthcare quality change (Bohnert et al., 2018). This is an important
addition to the quality change requirements and the nursing educators as well as the counselor
must be included in the health care teams as well. The use of electronic medical records and
the access of the health care database must be taught and trained to the new graduate nurses
as well so that they can comply with the evidence based practice guidelines and the access the

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patient information properly as well. In addition to the above quality improvement areas that
are addressed, it is critical to note that there is an increased need for clinical supervision as
well and the quality improvement change should incorporate the various audits systems –
such as the manual audits that would be done by nursing managers and the other health
officers in the organization (Rebane, Karlsson & Papapetrou, 2019). The electronic audit
system pertaining to the supervision and guidance of the new nurses in all the clinical
departments are equally important and vital and it is very important the new nurses should be
motivated in the proper manner to comply with the evidence based practice of medication
administration to prevent errors (Bailey et al., 2016). The rewards and recognitions scheme
can be a vital motivator for the proper clinical compliance with the medication administration
error is and important in the development of nursing compliance towards a responsible
behavior pertaining to medication administration. As for negative reinforcement, penalties in
terms of performance parameters can be efficient. Scoring system and grading the nursing
performance is important and critical way of teaching the ethical considerations in pertinence
to medication administration and prevent the possible errors (Bagattini et al., 2019).

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References
Bagattini, F., Karlsson, I., Rebane, J., & Papapetrou, P. (2019). A classification framework
for exploiting sparse multi-variate temporal features with application to adverse drug
event detection in medical records. BMC medical informatics and decision
making, 19(1), 7.
Bailey, C., Peddie, D., Wickham, M. E., Badke, K., Small, S. S., Doyle‐Waters, M. M., ... &
Hohl, C. M. (2016). Adverse drug event reporting systems: a systematic
review. British journal of clinical pharmacology, 82(1), 17-29.
Banda, J. M., Evans, L., Vanguri, R. S., Tatonetti, N. P., Ryan, P. B., & Shah, N. H. (2016).
A curated and standardized adverse drug event resource to accelerate drug safety
research. Scientific data, 3, 160026.
Bohnert, A. S., Walton, M. A., Cunningham, R. M., Ilgen, M. A., Barry, K., Chermack, S. T.,
& Blow, F. C. (2018). Overdose and adverse drug event experiences among adult
patients in the emergency department. Addictive behaviors, 86, 66-72.
Lee, K., Qadir, A., Hasan, S. A., Datla, V., Prakash, A., Liu, J., & Farri, O. (2017, April).
Adverse drug event detection in tweets with semi-supervised convolutional neural
networks. In Proceedings of the 26th International Conference on World Wide
Web (pp. 705-714).
Peddie, D., Small, S. S., Badke, K., Bailey, C., Balka, E., & Hohl, C. M. (2018). Adverse
drug event reporting from clinical care: mixed-methods analysis for a minimum
required dataset. JMIR medical informatics, 6(2), e10248.

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Rebane, J., Karlsson, I., & Papapetrou, P. (2019, June). An Investigation of Interpretable
Deep Learning for Adverse Drug Event Prediction. In 2019 IEEE 32nd International
Symposium on Computer-Based Medical Systems (CBMS) (pp. 337-342). IEEE.

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