Assessment 1: Adverse Event or Near-Miss Analysis  

Analysis of Adverse Event

Adverse events inevitably occur in healthcare and are actually common. An adverse event is an incident that occurs in a healthcare setting that results with an unintended clinical outcome (Liukka et al., 2020). They happen daily, even in the best of the best healthcare systems. How clinicians and hospital leaders respond to the adverse event is vital to preventing or limiting them from happening in the future. Many people are impacted by an adverse event, not just the patient. It includes their family, the clinicians involved, and the organization where it occurred. 

An example of an adverse event that occurred during my clinical practicing time is a 67 year old male patient was admitted to an intensive care unit (ICU) following open heart surgery for a valve replacement. Patients are started on Coumadin, which is blood thinning medication, following this surgery and have to remain on the medication for the rest of their life. This patient was prescribed a high dose amount of Coumadin and the order was put into the electronic medical record. With multiple competing priorities on the nurse’s to do list, when the Coumadin was due the ICU nurse took the medication from the Pyxis machine and administered it to the patient without checking the patient’s lab values for PT and INR. The INR was already elevated above 3.0 at 3.8 due to being on a heparin drip post-surgery. The Coumadin was ingested by the patient and the INR at the next blood draw was at 4.4, a critically high level. This was all happening at the same time the patient was starting to become confused due to the extended stay of over twenty days in the ICU. The confusion can sometimes be known as ICU psychosis. With the confusion the patient became a higher risk for falling. While the nurse was in another patient room during the evening part of her shift, she heard a cry for help and immediately went in to find the 67 year old patient on the floor. After assessing for immediate visible injury the patient was assisted by staff and put back into bed with fall alerts being put into place, along with a patient sitter at the bedside. Later that evening the confusion worsened and a head CT scan was ordered which showed a subdural hematoma, a result of the fall and having too many blood thinners onboard. Greater than one million people per year in the United States have had a medication error when in the hospital. These errors not only lead to higher patient concerns regarding safety but also higher health care costs (Walroth et al., 2017). In this case the fall, which was an adverse event, could have potentially been prevented if the nurse had implemented fall safety precautions after doing her assessment on the patient during her shift. She could have alerted the doctor and asked for orders to implement a bed alert or a bedside sitter with the patient. The fall which caused the subdural hematoma due to the Coumadin being administered resulted in a longer length of stay for this particular patient which led to higher medical costs. The length of stay was not complicated by any additional issues and the subdural hematoma resolved without surgery and the patient was started on Coumadin at a very low dose after the heparin was discontinued. 

The nurse did not receive any disciplinary action as a result of the event but was tasked with implementing a unit wide fall safety campaign to reinforce already in place fall safety protocols and to provide additional education to the staff on the importance of fall safety. . 

Analysis of Implications to Stakeholders

There are many stakeholders involved any time there is an adverse or near miss event, not just the nurse and the patient. These stakeholders include the patient, their family, the clinicians involved in the event and their peers, and the healthcare system. The first and most important being the patient who can suffer a poor clinical outcome and even possibly death. The patient’s activities of daily living (ADL’s) could be impacted if the subdural hematoma has long term impacts. Falls in an inpatient setting remain the leading cause of adverse events (Mikos et al., 2021). There is a difference in statistics depending on the type of inpatient unit it occurs in. Generally rehabilitation units are the highest incident rate (Mikos et al., 2021). Inpatient falls are also more likely to occur between midnight and 6:00am (Mikos et al., 2021). Reporting of raw number of falls is crucial in the development of future protocols to prevent or decrease them from occurring in the future. 

The second stakeholders that are impacted are the clinician. Those primarily affected are nurses because various new policies on intervening to prevent patient falls will likely be implemented. Nurses’ roles are high priority in addressing patient safety standards from assessing the patient’s fall risk, collaborating with other multidisciplinary team members, and implementing the new protocols (Montejano-Lozoya et al., 2020). For example in the example above the nurse could have questioned the physician, pharmacist, and herself regarding the safety of giving a patient already on heparin high dose of Coumadin. The nurse should have also checked the PT/INR lab result prior to giving the blood thinning medication, asked the nurse in charge if the order seemed okay once she knew the lab results, and outreached to the physician for further orders. Healthcare workers often times experience difficulties in their day to day tasks after and adverse event. 

The third stakeholder impacted by adverse events are the healthcare systems. Long standing impacts can occur to the healthcare system, especially if adverse events are underreported, such as financial stability, legal issues, and reputation (Liukka et al., 2020).

 Quality Improvement Technologies 

There have been many phases of quality improvement when it comes to technology. In the case described above, medication assisted delivery systems have evolved tremendously over time which include linking medication assisted delivery systems to electronic medical records (EMRs). An electronic medical record can coordinate many things that will impact the patient. This includes medications, physician orders, procedures and tests, as well as referrals (Martinez et al., 2017). Though the medication assisted delivery system could have had an alert populate to instruct the nurse to check the PT/INR lab value and alert the ordering physician prior to administering the Coumadin, the ultimate responsibility lies with the nurse prior to administering the medication. Healthcare systems need to investigate root causes of the adverse events. There are various tools in the industry that can assist with future prevention of medication assisted errors (MAE). This case described above was during a time when physicians were still handwriting orders, a practice that is rare in today’s healthcare world. Legibility and interpretation could have easily contributed to the error. Through the introduction of computerized provider order entry (CPOE) systems that integrate with EMRs, improvement in MAEs has been on the rise. The EMRs have also assisted with care coordination and improvement in patient safety from one department to another (Martinez et al., 2017). This medication error increased the length of stay of the patient and resulted in subsequent increased cost of care for the patient and payer. In the United States billions of dollars are spent to combat this issue (Schwendimann et al., 2018).

Incorporation of Relevant Metrics

While patient safety is top priority, financial impacts rank high as well and hospital administration and insurance payers are always looking at the cost of the care for their patients. There is a significant cost of approximately $14,000 USD per fall that results in an adverse event due to an increased length of stay (Mikos et al., 2021). This dollar amount can have much higher amounts if the adverse event results in a medical law case. Between 30-35% of falls that occur in acute care facilities lead to these significant costs (Mikos et al., 2021). An ICU patient is about ten times more likely to have a fall resulting in an adverse event if their length of stay is great than nineteen days (Mikos et al., 2021). Thus, reducing medication errors and fall reduction initiatives must be the top priorities of the health systems/ patient safety and quality committees. Recent studies show that when a physician orders medications through a CPOE system it reduces the likelihood of error on that order by 48% (Claffey, 2018). Lack of care planning by almost twenty percent, failure to update medical records timely, and reduced nursing care by roughly twenty three percent have led to these alarming statistics (Claffey, 2018). In addition nurse’s caseloads are significantly higher than they should be for nurses and their ancillary staff (aides, therapists, dietary support) as well as patient safely contribute to increase in medication errors and falls. 

Quality Improvement Initiative

Throughout the years many measures have been put into place to help nurse’s decrease medication errors that would lead to adverse events. Historically there have been five rights for nurses’ to use when administering medications: right patient, drug, route, time, and dose. This has worked fairly well at the patient’s bedside. The journey however starts long before the drug actually reaches the room of the patient. With that many organizations including the facility where the adverse event described above are implementing a new practices of a ten rights approach to ensure a safer practice for the nurse and resulting in better outcomes for the patient. Those ten rights include the five mentioned above and the patient and nurse’s right to refuse, knowledge, questions, advice, and outcome. While this may cause more work for the nurse, the reduction in medication errors that lead to falls far outweigh the cost of reducing the patient assignment of the nurse and long term impacts on the patient and facility (Claffey, 2018). 

In addition to the ten rights quality initiative, another other quality improvement initiatives model was applied in the healthcare system. The model proposed for rollout at the mentioned healthcare facility is a continuous quality improvement (CQI) model (O’Donell & Gupta, 2020). The model is a quality improvement tool that helps to enhance system processes, operations, regulatory compliance, and clinical outcomes. The tool may integrate with the EMR to ensure that it is effective and efficient. Collaboration among the facility’s interprofessional teams will be critical to the success of the initiatives.  

An adverse drug event (ADE) is harm experienced by the patient as a result of exposure to a medication like the subdural hematoma in the case example above (AHRQ, 2020). ADEs account for substantial ED visits and hospitalizations each year in addition to the increase in length and cost of stays increasing. An ADE doesn’t necessarily indicate the nurse and facility are providing poor quality of care but an act of or omission during the process (AHRQ, 2020). By rolling out the ten rights initiative paired with CQIs it is the hope to reduce the medication errors and adverse events that can result. 

Conclusion

Medication errors account for the majority of adverse events. There are serious implications for all stakeholders involved in the event. As noted these events can be prevented or decreased when processes are vetted to look at the cost of bringing in new technology versus the cost of the error and the lasting effects to the stakeholders. These new technologies can improve the overall experience of the each stakeholder as they push to move forward. 

References

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