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

ADVERSE EVENT OR NEAR MISS ANALYSIS
1
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

ADVERSE EVENT OR NEAR MISS ANALYSIS
2
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.