Assessment 1: Adverse Event or Near-Miss Analysis
An adverse event refers to an injury caused by medical interventions rather than the underlying condition. It prolongs hospitalization, causes a disability during discharge, or both. Preventable adverse events are injuries that occur owing to an error or failure to implement an established guideline for prevention (AHRQ, n.d.). A near miss event refers to a hazardous situation that is indiscernible from a preventable adverse event, excluding the outcome. The purpose of this paper is to comprehensively analyze a near-miss event that I experienced during my professional nursing practice.
Missed Steps or Protocol Deviations Related To an Adverse Event or Near Miss
As a new-grad nurse working on a medical-surgical floor, I experienced a near-miss event when I transfused the wrong blood to an anemic patient. The patient’s blood group was B+, and I administered AB+ packed red blood cells (PRBC). The floor had two patients requiring blood transfusion, and two PRBCs were delivered in the blood carrier box, one containing PRBC AB+ and the other B+ PRBC. Being a busy shift and we were short-staffed, I deviated from the hospital’s blood administration protocol that indicated that two qualified registered nurses must be present during a blood transfusion. The protocol also stated that each patient undergoing transfusion must be positively identified. The patient identifiers on the identification band must accurately match those on the blood component label. I deviated from the protocol, which led to administering ABO-incompatible PRBCs.
The blood administration error was identified approximately five minutes later when I was administering the other PRBC product to the second patient. When confirming the second patient’s name, blood product, and ABO compatibility, I realized that I had administered the wrong blood to the first patient. I immediately stopped the transfusion, took the vital signs, and informed the attending physician, who prescribed Hydrocortisone IV to prevent hypersensitivity reaction. Luckily, the patient did not experience any show signs of hypersensitivity. The incident was 100% preventable if I had followed the hospital’s blood administration guidelines, which state that the final check must be carried out next to the patient by two trained and competent healthcare providers who must also administer the component. Besides, if I had confirmed the right patient, blood product, and ABO compatibility in the patient with another nurse, the incident could not have occurred.
Blood administration errors have had an adverse impact on other facilities. Errors in identification (of patients, blood samples, and blood components) by health providers are the primary cause of most transfusion errors incidents, including ABO-incompatible transfusions (Ramsey, 2020). The incident results in severe acute transfusion reactions, which are the greatest cause of major morbidity in health facilities. Hospitals have also faced lawsuits from patients due to transfusion errors. However, the specific procedures that hospitals have taken to reduce such incidents are unknown, and information on this could enhance the analysis.
Implications of the Adverse Event or Near-Miss for All Stakeholders
The near-miss event has short- and long-term implications for stakeholders, including the patients, families, interprofessional team, and the organization. Short-term effects on patients include immunological reactions like hemolytic reactions, allergy/anaphylaxis, lung injury, circulatory overload, and bacterial contamination from blood components (Bolton‐Maggs & Watt, 2020). Long-term implications include renal failure and disseminated intravascular coagulation. The chances of mortality increase directly with the amount of incompatible blood transfused (Ramsey, 2020). Implications on the patient’s family include high healthcare costs used in managing the patient’s morbidities and the loss of loved ones. The interprofessional team risks losing their licenses if they are sued by the patient and found guilty of malpractice (Bolton‐Maggs & Watt, 2020). In addition, the risk of paying huge fines and even facing a jail term for professional negligence. The organization can face lawsuits from patients, which lead to huge fines and even closure on the grounds of professional negligence by employees.
Each interprofessional team member has a responsibility to create a culture of safety. The nurse supervisor is responsible for allocating duties equally and ensuring that crucial procedures such as blood transfusion are handled by the recommended number of staff. Nurses were responsible for ensuring that the nurse administering blood had an assistant to help confirm the patient, blood product, and ABO compatibility (Bo
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