Adverse Event or Near-Miss Analysis
Healthcare organizations have prioritized service delivery and quality improvement. The US government has even gone to the extent of making certain adverse events illegal. Despite efforts to curb adverse events and near misses, the American health system continues to report an unprecedented increase in the number of these events. Studies have established that adverse events are the primary reason for health complications causing extended hospitalization, disabilities, and in some cases death. Adverse Event or Near-Miss Analysis.Clinical researchers attribute a majority of adverse events and near misses in the US to communication issues and psychiatric disorders. Communication mishaps between patients and health providers increase the risk of adverse events. Medication errors are also to blame for a significant percentage of adverse events and near misses. This analysis picks out an adverse event I witnessed during nursing practice and identifies a quality improvement initiative to address the issue. Adverse Event or Near-Miss Analysis.
Identification of the Adverse Event/Near-Miss
The adverse event in question highlights a medication error at the prescription stage at the Mary Leakey Renal Center. The occurrence is preventable as it relates to drug dosage and patient medication. The patient in the scenario is a 72-year-old man, Ronald Drake, with kidney issues and was in dire need of kidney dialysis. His treatment procedure included an initial administration of human albumin, after which Mr. Drake contracted dyspnea. After some time, the man developed breathing complications and the oxygen saturation dropped to about 75% causing tachycardia issues. The health provider attending to Ronald thus prescribed epinephrine, following which the patient had to be accorded intensive care. A detailed medical examination revealed that Mr. Drake was traumatically allergic to Human Albumin, a condition known as anaphylaxis. Adverse Event or Near-Miss Analysis.
Analysis of the Adverse Event/Near-Miss
The adverse event is a result of an unforeseen medication error during kidney dialysis. The health providers in the organization deviated from the relevant protocol, which involves examination for allergies, thus, warranting the adverse event or near miss (Jylhä, Bates, & Saranto, 2016). The medication error resulted in anaphylaxis, which is a life-threatening reaction that requires immediate medical attention. In the course of ill-treatment, anaphylaxis can be fatal. The condition, however, was adequately managed to evade death. The medication mishap is a clear indication of the need for intensifying clinical research, medical resources, and medication prescription to enable healthcare providers to establish probable drug interactions and reactions beforehand. Adverse Event or Near-Miss Analysis.
The adverse event/near miss in question is preventable since medication errors are identifiable and can be avoided. The physician in charge administered Human Albumin, on the first instance, while the patient was undergoing dialysis. Such a prescription infers that the clinician assumed that Human Albumin works well with the patient and that the patient had no record of an allergic reaction to the drug. From my observation, the healthcare provider did not perform any tests to verify the suitability of the drug before administering it to Mr. Drake. The physician did not also see a reason to mention the prescription to the patient or their caregivers but went ahead and injected Mr. Drake with Human Albumin.
The medical mishap at hand can be attributed to a lack of communication between the patient and providers, and perhaps sheer ignorance on the part of the healthcare providers (Jylhä, Bates, & Saranto, 2016). Adverse Event or Near-Miss Analysis.The clinician’s utter confidence while he made the drug prescription and their ignorance towards the possibility of a drug reaction could be subject to inadequate exposure during nursing education and training. Also, the nurse who administered the medication did not at any point suspect that the patient could be affected by Human Albumin even at his (Mr. Drake’s) age. The clinician and the nurse could have easily avoided the mishap by involving the patient or their caregiver. In this case, the near-miss would have been fatal if the right intervention would not have been provided in due time.Adverse Event or Near-Miss Analysis.
Implications of the Adverse Event
Every health system, including that of the US, is prone to experience adverse events or near misses related to unforeseen errors. Such events have significant impacts on medical personnel, patients, their
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