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


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

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


Capella university

NURS-FPX 6016 Quality Improvement of Interprofessional Care

Prof. Name


Adverse Event or Near-Miss Analysis

In the complex and dynamic healthcare environment, patient safety remains paramount. Despite significant advancements in medical technology, training, and protocols designed to safeguard well-being, adverse events and near misses continue to occur, posing substantial patient risks and challenging healthcare professionals to seek continuous improvement. This assessment delves into the critical analysis of a specific adverse event or near miss encountered in professional nursing practice, aiming to dissect the multifaceted layers contributing to such incidents.

Through a detailed examination, this report sheds light on the immediate and underlying factors leading to the event and proposes a comprehensive Quality Improvement (QI) initiative tailored to address these issues. By integrating evidence-based practices and leveraging insights from existing research, the initiative seeks to enhance patient safety, reduce the incidence of similar events in the future, and foster a culture of proactive risk management within healthcare settings. This assessment underscores the importance of reflective practice, interdisciplinary collaboration, and the relentless pursuit of excellence in patient care, embodying the commitment to turning challenges into opportunities for systemic improvement.

Analysis of Implications of an Adverse Event or a Near Miss for All Stakeholders

In my nursing practice, I encountered an event involving a 68-year-old male patient with a history of chronic heart failure and atrial fibrillation, for whom a regimen of Digoxin was prescribed to control his heart rate. This patient, Mr. Caldwell, had been under our care for several weeks, and the familiarity with his case had bred a sense of routine amongst the staff. One day, due to a manual entry error into the electronic health record (EHR), Mr. Caldwell was nearly administered a dose of Digoxin that was double the intended amount. The error was caught in the nick of time by a junior nurse who, out of due diligence, cross-referenced the medication administration chart with the electronic prescription orders before administering the dose. The potential implications of this near miss were significant for all involved.

Had the error not been caught, Mr. Caldwell could have faced immediate adverse effects, such as Digoxin toxicity, characterized by nausea, dizziness, confusion, and potentially life-threatening arrhythmias. The long-term trust he placed in our facility and his confidence in receiving safe care could have been irreparably damaged. For Mr. Caldwell’s family, the incident brought about a sudden and acute awareness of the risks involved in hospital care, potentially affecting their peace of mind and trust in the healthcare system going forward.

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

The interprofessional team, comprising nurses, pharmacists, and physicians, was reminded of the critical importance of vigilance at all stages of medication administration. The near miss necessitated a reevaluation of our medication verification processes. She prompted discussions about enhancing safety measures, such as implementing more robust double-check systems and increasing training on EHR systems to prevent similar errors. The responsibilities of each team member were reinforced, highlighting the need for continuous communication and verification at every step of the medication administration process.

Following the incident, measures were put in place to prevent recurrence. These included mandatory double-checking of all medication orders by nursing staff and pharmacists before administration, especially for high-risk medications like Digoxin. The incident also led to an immediate audit of the EHR system to identify and correct any vulnerabilities that could lead to similar errors. Training sessions were organized for all staff members to reinforce the importance of adherence to protocols and to educate them on the new safety measures implemented.

The impact on the facility was multifaceted. It prompted a review of our medication safety protocols and led to the adoption of stricter guidelines for medication administration. This near miss also became a catalyst for change within the facility, leading to a more open culture that encourages reporting errors and near misses without fear of retribution. It became a learning opportunity for the staff directly involved and the entire organization, underscoring the importance of constant vigilance, ongoing education, and the adoption of best practices in patient safety. This incident did not alter how we administer medications; it transformed our reporting culture, making it more transparent and proactive. It reinforced the idea that a near miss is a chance to improve and prevent actual harm, making our facility safer for our patients and a more supportive environment for our staff.

Root Cause Analysis

In the RCA of the near miss involving the administration of Digoxin to Mr. Caldwell, it was found that manual entry errors and a lack of stringent double-check procedures were primary contributors. The event was a direct result of these errors in medical management, not Mr. Caldwell’s underlying heart condition. The RCA highlighted the omission of a crucial safety step: verifying medication orders against the patient’s chart and original prescription, a practice that has been shown to reduce medication errors significantly (Ives et al., 2020). This analysis also pinpointed a breakdown in interprofessional communication. This near-miss could have been averted if a mandatory consultation or verification process existed between the prescribing physician and the pharmacy team. The importance of such interprofessional collaboration is well-documented in reducing medication errors, particularly with high-risk medications like Digoxin (Cooper et al., 2019).

Furthermore, the RCA revealed that this adverse event was highly preventable. Implementing an electronic medication administration record (eMAR) system with built-in checks for dose verification could have prevented the manual entry error. Additionally, establishing a culture that encourages and facilitates open communication among all healthcare team members could have provided additional safeguards against this near miss (Ives et al., 2020). The findings from the RCA underscore the critical need for systemic changes within the medication management process, including adopting technology that supports error prevention and fostering an environment that promotes rigorous communication practices among healthcare professionals. These changes are essential for enhancing patient safety and preventing future medication errors.

Quality Improvement Actions

In the wake of the near-miss incident involving Digoxin administration, our healthcare facility undertook a comprehensive evaluation of existing quality improvement technologies and practices to identify measures that could significantly reduce risks and enhance patient safety. The EHR system is a critical technology equipped with advanced clinical decision support (CDS) functionalities. These systems are designed to alert prescribers to medication errors, such as dosage anomalies or drug interactions, at the point of care. To prevent similar adverse events, our facility is exploring the augmentation of EHR capabilities with a more sophisticated CDS algorithm incorporating patient-specific factors, such as renal function or concurrent medications, to provide more precise dosing recommendations (Lahti et al., 2022).

While beneficial, the current utilization of these technologies revealed areas for improvement. For example, the incident underscored that reliance on automated alerts alone is only sufficient with a complementary process that ensures human oversight. Consequently, we are implementing a mandatory secondary review of all high-risk medication orders by a clinical pharmacist before dispensation, a practice supported by findings from the Mayo Clinic’s safety protocols, which have been shown to reduce medication errors significantly (Mayo Clinic, 2021).

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

Comparatively, institutions like Johns Hopkins Hospital have set industry benchmarks in patient safety by integrating a comprehensive medication management system that includes barcoding and real-time medication tracking (Johns Hopkins Medicine, n.d.). These systems prevent medication errors at the point of administration and facilitate a closed-loop medication administration process that ensures the right patient receives the proper medication at the correct dose and time.

From our facility’s dashboard, data metrics such as medication error rates, patient satisfaction scores, and readmission rates are closely monitored. Following the implementation of enhanced EHR and CDS functionalities, a notable decrease in medication error rates was observed, from 5 errors per 1,000 doses to 2 errors per 1,000 doses over six months. Patient satisfaction surveys also reflected improved confidence in the care provided, with scores increasing by 15% post-implementation.

External data from the National Healthcare Safety Network (NHSN) indicate that medication errors remain a significant challenge across the healthcare industry, with an average of 4 per 1,000 doses nationally (CDC, 2023). Our internal metrics, post-enhancement of our EHR and CDS systems, show our facility performing better than the national average, indicating the effectiveness of our targeted quality improvement actions.

Quality Improvement Initiative

Following the evaluation of a near miss involving medication administration, our healthcare institution has committed to launching a comprehensive QI initiative to bolster medication safety and prevent future adverse events. This initiative, grounded in the synthesis of evidence-based practices and the lessons gleaned from our incident analysis, is designed to be dynamic, incorporating ongoing review and adaptation based on emerging data and feedback. The Enhanced Medication Management System (EMMS) initiative is structured around four key components: advanced technological integration, targeted educational programs, policy enhancement, and the promotion of a safety-first culture.

  • Advanced Technological Integration: Leveraging the findings from studies such as those by Shermock et al. (2023), which highlight the effectiveness of CDSS in reducing medication errors, EMMS proposes implementing an upgraded EHR system with integrated CDSS. This system will feature real-time alerts for potential medication errors, including dosage discrepancies and drug interactions.
  • Targeted Educational Programs: Recognizing the critical role of healthcare professionals in medication safety, EMMS includes the development of comprehensive training modules. These modules will focus on best practices in medication administration, new technologies, and strategies for effective communication across the care team. The importance of continuous education is underscored in the research by Berry et al. (2020), demonstrating a significant correlation between staff training and a reduction in medication errors.

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

  • Policy Enhancement: Building upon the insights provided by the World Health Organization (WHO, 2019), which advocates for clear medication management policies as a cornerstone of patient safety, EMMS will introduce revised protocols for medication verification and administration. This will include mandatory double-checks for high-risk medications and a structured communication process for prescription clarifications.
  • Promotion of a Safety-First Culture: An essential element of EMMS is fostering an organizational culture that prioritizes safety and encourages reporting errors and near misses. Drawing on the model proposed, which emphasizes the importance of a just culture in healthcare settings, EMMS aims to create an environment where staff feel empowered to speak up about potential safety issues without fear of retribution (Ives et al., 2020). The development of EMMS meticulously evaluates diverse research findings, noting that while CDSS implementation enjoys widespread endorsement, it also faces critiques concerning alert fatigue issues (Shermock et al., 2023). In response, EMMS plans to introduce customizable alert settings. Additionally, it commits to regular system evaluations. These steps optimize CDSS effectiveness and prevent user overload, ensuring the system enhances rather than impedes the medication management process (Ghazi et al., 2022).


In addressing the adverse events within nursing practice, this assessment has highlighted critical areas for improvement and patient safety. The proposed Quality Improvement (QI) initiative offers a strategic pathway to enhance care standards through technology, education, and a safety-centric culture. It emphasizes the critical role of continuous vigilance and interdisciplinary cooperation in preventing future incidents. Ultimately, this approach reinforces the commitment to maintaining patient safety as the cornerstone of healthcare excellence.


Berry, J. C., Davis, J. T., Bartman, T., Hafer, C. C., Lieb, L. M., Khan, N., & Brilli, R. J. (2020). Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system. Journal of Patient Safety16(2), 1. 

CDC. (2023). National Healthcare Safety Network (NHSN) Patient safety component manual 

Cooper, J. B., Jeter, E., & Sessoms, C. J. (2019). Rates and types of medication-related problems in patients rehospitalized within 30 days of discharge from a community hospital. Journal of Pharmacy Technology36(2), 47–53. 

Ghazi, L., Yamamoto, Y., Riello, R. J., Coronel-Moreno, C., Martin, M., O’Connor, K. D., Simonov, M., Huang, J., Olufade, T., McDermott, J., Dhar, R., Inzucchi, S. E., Velazquez, E. J., Wilson, F. P., Desai, N. R., & Ahmad, T. (2022). Electronic alerts to improve heart failure therapy in outpatient practice: A cluster randomized trial. Journal of the American College of Cardiology 

Ives, A. L., Tucker, S. R., & Trovato, J. A. (2020). Using electronic health record technology to teach inpatient medication order verification to pharmacy students. American Journal of Pharmaceutical Education84(8), ajpe7534. 

Johns Hopkin Medicine. (n.d.). Medication Management. 

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

Lahti, L. C., Kivivuori, S.-M., Lehtonen, L., & Schepel, L. (2022). Implementing a new electronic health record system in a university hospital: The effect on reported medication errors. Healthcare10(6), 1020. 

Mayo Clinic. (2021, February 7). Medication errors: Cut your risk with these tips. Mayo Clinic News Network. 

Shermock, S. B., Shermock, K. M., & Schepel, L. L. (2023). Closed-loop medication management with an electronic health record system in U.S. and finnish hospitals. International Journal of Environmental Research and Public Health20(17), 6680. 

World Health Organization. (2019). Medication safety in high-risk situations. 

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