Case Study Report: Adverse Event Management in Acute Care Nursing

This report presents a case study focusing on an adverse event involving a 7-year-old boy in an emergency department who experienced a medication error. The report details the patient's presentation, principal diagnosis (Colles fracture), and the adverse event, which involved the administration of an incorrect dosage of ketamine. It describes how the event was managed by nursing and medical staff, including the immediate response to the patient's respiratory depression. The report analyzes the current workplace system, referencing the National Safety and Quality Health Service Standards by the Australian Commission on Safety and Quality in Health Care, and compares these systems to best practice guidelines. It identifies areas for improvement in the management of adverse events, emphasizing the need for preventive measures such as proper dosage verification and the implementation of medication safety protocols. The conclusion offers recommendations regarding changes required in clinical practice to minimize the occurrence of similar incidents.

CORE CONCEPT IN ACUTE CARE NURSING
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TABLE OF CONTENTS
Introduction......................................................................................................................................3
1. Define adverse event....................................................................................................................3
2. Introduce the patient....................................................................................................................3
3. Brief summary of patient’s principal diagnosis, past medical history, medication and relevant
results...............................................................................................................................................4
4. Describe the patient’s adverse event. What happened? How the patient’s adverse event
managed by nursing and medical staff............................................................................................4
5. Analyze current workplace system with best practice guidelines to manage this event.............5
6. Compare current workplace systems for managing this event. What does the Australian
Commission on Safety and Quality in Health Care suggest............................................................6
7. Identify areas for improvement in the management of adverse events.......................................7
7. Conclusion and Recommendations regarding changes required in the practice.........................7
References........................................................................................................................................7
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INTRODUCTION
Adverse events depicts errors and mistakes in the process of medication which causes
injuries and problems to the person. Thus, in such respect the present research study has been
describing the impact of adverse event on the patient. The entire study has been conducted on the
basis of a case study which denotes the issue of medication error. Furthermore, in the research
study discussion has also been included regarding guidelines that are essential to be followed
especially at the time of managing adverse events. Lastly, considering this aspect
recommendations have been given to manage the impact of adverse events in health care sector.
1. DEFINE ADVERSE EVENT
Adverse events are defined as incidents wherein harm is resulted to a person who
receives health care. Adverse event usually happens because of medication errors and that also
makes the health condition more critical and severe. Adverse event include infection, falls results
in injuries and improper use of medical devices (Andersson and et. al., 2015). In the area of
clinical practice, an unfortunate medical occurrence that may present during the event with any
sort of medical error which has a causal relationship with the treatment.
Thus, in other words, adverse events is called as injury to patient that occurs due to errors
in medication. This states that hospital and medical care service providers are engaged in the
medical error that causes injuries and harm to the respective patient. The impact of adverse
events can be highly dangerous because improper emphasis on medical aspects can bring severe
challenges to the patient (D’Amour and et. al., 2014).
Apart from this, adverse event may also be called as incidents happened in the hospitals
due to errors in practices and also due to changes in the medicinal doses. Adverse events directly
generates medical burden and at the same time it also enhances liabilities of the hospital towards
the patient.
2. INTRODUCE THE PATIENT
The present study has been focusing on a 7 years old boy who was healthy admitted in
the emergency department because of swilling in his right arm. While running, he fell down on
his outstretched arm and after that he started complaining of severe pain in his wrist. The boy
does not have any sort of allergies in the body. However, when he feel down, the left wrist
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became swollen, tender and reddish and as a result, this has developed fear in the child regarding
the level of pain.
3. BRIEF SUMMARY OF PATIENT’S PRINCIPAL DIAGNOSIS, PAST MEDICAL
HISTORY, MEDICATION AND RELEVANT RESULTS
While conducting the physical examination, it is analysed that the boy’s HR is 150, RR is
28, Sat is 100% in RA, and Temperature is 37C and weight is 30 Kg. The left wrist is swollen;
hence that part has started aching. While conducting other clinical examinations, everything was
normal. X-ray was also conducted and it showed Colles fracture with displacement and
angulation of the distal end of the radius. After analysing the medical condition, the physician
decided to do close reduction by applying the cast.
Thus, to reduce the criticality of the condition, doctors decided to prescribe 2 mg of
ketamine and accordingly he wrote 60mg IV once. Prior giving any sort of medicine, the nurse
informed the other nurse (who was busy) to take 20 of ketamine. After such procedure, the
medication was given and the doctor started the process of reduction (Gaal and et. al., 2014).
While carrying out the procedure, the monitor started to show desaturation to 90% which kept on
changing. At the same time, problems were also observed in respiratory rate; hence that led the
team to prepare for intubation for the purpose of maintaining the airway. Finally, after reviewing
the entire situation, it is analysed that the child received 20 ml instead of 20 mg of Ketamine.
4. DESCRIBE THE PATIENT’S ADVERSE EVENT. WHAT HAPPENED? HOW THE
PATIENT’S ADVERSE EVENT MANAGED BY NURSING AND MEDICAL STAFF
Considering the above discussion, it is clear that there was medication error caused by the
hospital which made the boy’s condition severe. The large dose of sedative medication is highly
severe and dangerous too; hence it caused a deeper and prolonger sedation effect. As a result,
child’s respiratory rate got depressed which generated the need of respiratory system. The nurses
did not take care of the dosage and mistakenly, high dose was given to the boy. That made the
condition serious (Kalisch, Xie and Dabney, 2014). At the time of observing the critical
condition when the respiratory rate decreased, then during such time nurses gave bagging with
self- inflating bag for 1 minute. This was done for the purpose of maintaining the airway.
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5. ANALYZE CURRENT WORKPLACE SYSTEM WITH BEST PRACTICE GUIDELINES
TO MANAGE THIS EVENT
The National Safety and Quality Health Service Standards were typically developed by
the Australian Commission on Safety and Quality in Health Care for the purpose of consulting
and collaborating with jurisdiction regarding nursing regulation. The main aim of developing
such standard is to prevent and safeguard the public from harm. Similarly, it also requires focus
to improve the quality of care by the service organizations (DiCenso, Guyatt and Ciliska, 2014).
Thus, in order to manage best practice in the care entity, the hospital is requisite to emphasize on
a quality assurance mechanism that focuses on checking the relevancy of the system. This
regulation will also assist the hospital to maintain minimum standards for safety and quality
while delivering medical care services.
In order to manage adverse event, it is essential for the hospital to focus on proper dosage
of medicines. While specifying the prescription, it is crucial for the nurses to read it properly so
that chances of medication error can be avoided (Potter, Perry and Hall, 2016). The guidelines
developed under Safety and Quality aspects needs to be maintained as they are intended to
enhance the efficiency of health care services. Adverse events imposes greater responsibility on
the hospitals and this also requires to adopt different tasks that can change the value of service
provision. Adverse drug reaction can impact the patient’s medical condition and this can also
bring other health consequences (Boltz and et. al., 2016). Thus, to manage such thing, it is
essential for the hospital to make a list of all medicines so that according to the dose, medicines
can be provided. Besides this, there must be continuous emphasis on controlling and monitoring
aspects of the medication procedure so that to facilitate best practice in the care provision.
This also requires implementation of FMEA (Failure modes and effects analysis) which
is a systematic and proactive method that evaluates a process that identify where and how might
service provision has changed (LoBiondo-Wood and Haber, 2014). Thus, this is useful in
analysing the relative impact of different failures for the purpose of ascertaining the processes
that requires changes and modifications. However, at the same time, medicines that have a high
risk of causing serious injuries and death to a patient needs to be properly stored. Apparently,
errors with these products are not common; however the effects can be severely dangerous. A
few examples include blocking agents in the body and concentrated anticoagulants. Further, in
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this area, hospital should also focus on Drug and therapeutics committee which is typically
regarded as a group that is assigned several responsibilities for governance of medication
management system (Thomas, Phillips and Coventry, 2014). This also ensures safe and effective
use of medicines that is used in health service organization.
6. COMPARE CURRENT WORKPLACE SYSTEMS FOR MANAGING THIS EVENT.
WHAT DOES THE AUSTRALIAN COMMISSION ON SAFETY AND QUALITY IN
HEALTH CARE SUGGEST
Australian Commission on Safety and Quality in Health Care is a government agency
that was established for managing the process of medication in effectual manner. The framework
has a provision of medication safety in which the commission has identified the importance of
improving the safety and quality of medication usage in Australia (Sahay, Hutchinson and East,
2015). This was one of the priorities mentioned under NSQHS standard. This is significant in
terms of reducing error and harm from medicines through safe and quality. This also requires
coordination with national safety and quality improvements in health care. In Australian health
care entities, several national indicators for quality use of medicines are being adopted which are
also intended to support local monitoring of compliance with other necessary standards. This
includes processes of care that are related to medication management which is highly suitable in
improving health outcomes (Carter, 2016).
However, on the other hand, in the existing case, the hospital has implemented
generalised care procedure in which health and safety measures are being followed. In this
dimension, it is essential for the nurses to review the medication incidents and along with that,
proper monitoring is also required (Brandis and et.al. 2017). At the same time, medication
incidents are primarily important incidents in Australian hospital to facilitate monitoring
systems. In this context, The Medication Safety Standard requires to be implemented as a major
health care system because that aids in reducing medication errors and incidents. Similarly, it is
also significant in terms of improving safety and quality aspects in medicinal usage. Thus, in this
respect the aim of the standard is to develop safety practices in the clinics and hospitals.
Moreover, appropriate medicines are also required to be adopted for the purpose of monitoring
the effects of medication process (Johnson, Sanchez and Zheng, 2016).
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Several tools are available in order to manage adverse events such as voluntary and
mandatory reporting from internal hospital systems that requires state and federal system. In this
tool, patients themselves review the medication through reviewing diverse sources (Wu and et.
al., 2017). Apart from this, document review process can also be conducted that includes
patient’s charts, medical- legal documents, death certificate and complaint reports. Nurses are
also required to focus on automated surveillance of patient’s treatment data in the clinical record
system. This is useful in anticipating the conditions that could lead to adverse events in the
health care entity.
7. IDENTIFY AREAS FOR IMPROVEMENT IN THE MANAGEMENT OF ADVERSE
EVENTS
There are several areas of improvement that requires attention especially for the purpose
of reducing the opportunities of adverse events and incidents. Apparently, adverse events can be
occurred through any of the medication error; therefore in this realm it is vital for the hospital to
adopt various preventive measures to minimize such incidents (Tarhini, 2013). While giving
dosage of the medicines, it is essential for the nurses to ascertain it properly so that patient can be
protected from hazardous events. In terms of improvements, it can be said that the hospital
should also start the provision of medication safety so that suitable amount of medication can be
given to the respective patient. It is also mandatory for the hospitals to take immediate action for
adverse events and the doctors should also adopt necessary measures to administer the condition
(Martinez and et. al., 2017).
Adverse events are quite uncertain; henceforth proper safeguarding measures should be
adopted so that errors and mistakes can be avoided on higher extent. This also suggest that there
must be suitable consideration in practice improvement so that the chances of adverse events can
be reduced (Lencioni and et. al., 2015). Moreover, in this context it can also be said that along
with medication process, it is also vital for the care practitioners to focus on health and safety
measures so that risks and challenges can be avoided directly. In this respect, it can also be said
that to improve the service delivery procedure, hospitals must have to implement several care
provisions that can enhance the service delivery aspects. Moreover, in this context it is clear that
according to Australian Commission on Safety and Quality in Health Care, several standards
should be determined enhancing the care dimensions (Andersson and et. al., 2015).
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7. CONCLUSION AND RECOMMENDATIONS REGARDING CHANGES REQUIRED IN
THE PRACTICE
The health and social care sector is quite crucial and requires keen intervention and
supervision by the medical professionals. The conditions of child would not have become worse
if there was proper care taken before giving the medical dose. Clinical commissioning groups
have been formulated by the government for controlling and supervising the activities which take
place in the health and social care sector (Transforming our health care system, 2015). Following
are some of the recommendations which can be followed for making the health and social care
practises more efficient and reducing the probability of adverse events:
 Supporting self management is the primary step which can be taken by health care
practitioners for developing healthy behavioural attributes. Individuals that are suffering
from chronic diseases or long term health illness should be taught to take primary steps at
their own level so that in case of emergency certain rehabilitation methods can be
adapted. The overall burden of providing specific medications and treatment is reduced
when self management is possible at patient's end (Lencioni and et. al., 2015).
 Systematic detection of disease and providing appropriate intervention should be
provided by the practitioners before development of full symptoms. This kind of practise
is considered as secondary intervention and these have a significant impact over the
results or outcomes of health status of the individual.
 Care coordination in different health care settings helps in reducing the chances or
probability of negligence towards the patients. Be it individuals with chronic diseases or
the ones with complex physical and mental conditions, there has to be coordination
amongst care givers so that the effectiveness of respective treatment reduces (Thomas,
Phillips and Coventry, 2014).
Aforementioned recommendations can be applied in the health and social care settings in
the below mentioned ways: Primary prevention: Advices should be provided to patients and their relatives at the
time of consultation is one of the techniques for providing tips over self management.
The use of a combination of interventions for a particular treatment can be introduced
completely dependent on the suitability and feasibility of outcomes.
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 Secondary prevention: Low technology and cost effective interventions can be provided
only when there is proper screening and knowledge of the preventive measures. The
health practitioner has to develop sense of responsibility towards the patient and make it a
point to deliver the best service (D’Amour and et. Al., 2014).
 Care coordination: Health care plans and programmes can be developed collectively by
the respective groups and communities for bringing in coordination amongst different
groups and settings (Transforming our health care system, 2015).
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