Over the past decades, the role of human errors in the workplace setting has been a widely discussed topic (Gnoni & Saleh, 2017). One aspect contributing to these accidents or events in the workplace relates to “near misses.” Different kinds of literature provide distinct definitions of what near-miss entails. In safety management, the World Health Organization defines a near miss as any act of omission or commission which would have either harmed or led to adverse outcomes for a patient, but the harm did not occur as a result of either chance, mitigation, or prevention (Gnoni & Saleh, 2017). According to the current statistics, near misses to actual accidents are approximately 300: 1. Although these findings may not be a complete representation of all the incidents that occur in the workplace, they can form a basis for identifying opportunities for continuous improvements in the safety of any organization. Some of the factors that may be revealed during the analysis process may include noting the precipitating factors to the near-miss events, including human errors, and addressing them promptly before their occurrence (Gnoni & Saleh, 2017). As a nurse, I have encountered a wide range of near misses that would have otherwise harmed a patient if an interception was not done promptly, hence the need to pay close consideration to this area of interest. This essay analyses a near-miss situation that happened in a patient’s management in my facility, its implications to stakeholders, quality improvement technologies to the near-miss, and quality improvement initiatives to prevent the occurrence of a near miss.
Analysis Of the Near-Miss Event
I have experienced a near-miss at the emergency department, which would have otherwise harmed the patient if it was not intercepted on time. Marko, a 68-year-old male on anticoagulation and a recent diagnosis of deep venous thrombosis (DVT), came to the emergency department and reported feeling dizzy. When the vital signs were taken, Marko had a pulse of 46 beats per minute, an aspect that the healthcare workers at the emergency department believed was causing him to experience his symptoms. Upon taking a detailed history, Marko also revealed that he had been a hypertensive patient for the past seven years, and he had lately increased his beta-blocker. Being a hypertensive patient, he needed his beta-blockers to help slow down his heart’s pace. However, beta-blockers need to be taken in the required dosages since an overdose may result in the heart slowing further and may stop beating altogether. Due to the information gathered from history taking, the medical officer at the emergency department was worried that Marko’s heart rate would slow down further. As a result, the physician requested that a syringe with atropine should be placed at Marko’s bedside so that it could be used just in case his heart slowed further. On most occasions, atropine is used as an urgent medication to raise the heart rate during emergencies. However, it needs to be used under a medical prescription, and if it is not used correctly, it may lead to rapid heart rate and confusion.
As Marko was being stabilized in the emergency department, his heart improved, and he no longer needed the atropine. As a result, plans were made to discharge him home. However, he was to be switched on lower doses of his beta-blockers since they were not doing good to his heart. However, further investigations noted that his international normalized ratio (INR) when using Warfarin was also low. As a result, the discharge plan was also to discharge Marko with Low molecular weight heparin (LMWH), which he would inject himself two times a day. After the patient was taught several times how to self-administer the heparin, the nurse felt that he could do it comfortably, although the patient verbalized some difficulties in doing it. The nurse then gave the patient 15 syringes that had already been prefilled with heparin. The patient was to use this LMWH for two weeks until the time when he would visit the special clinic to be checked on how his DVT was progressing. When packing, the patient took everything that was on his bedside, including the box of atropine which was not administered. The next day, as the patient was trying to inject himself, he took the atropine syringe, which upon pressing, the entire atropine splashed on his stomach. Assuming the atropine syringe had a needle on it, the patient would have injected himself, which would have led to his heart rate beating rapidly, leading to further adverse outcomes. Marko felt confused and called the pharmacist, and when asked to read what was written on the box, he noted that it was atropine. The pharmacist later asked him to discard it since he accidentally took it. Although the patient was not harmed, this near-miss would have led to an adverse event if it happened.
This near-miss arose from the patient’s management and not the underlying condition. At the patient level, he could not effectively distinguish between atropine and LMWH. Additionally, the failure of the patient to inject himself properly and the fact that he scoped everything that was on his bedside without asking indicates a missed protocol. The hospital also failed to have a nurse by the patient’s side to prevent him from packing the atropine medication. As a result, this deviation would have contributed to grave outcomes for the patient if it is not prevented in the future. Lastly, the manufacturer also contributed to this error by making the syringes of heparin and atropine look similar. The combination of all these aspects contributed to the near-miss.
Near misses are referred to as close falls because it allows for considerations that reach the patient (Gnoni & Saleh, 2017). The near-miss would have been prevented if the stipulated protocols had been followed when analyzing this scenario. For instance, since atropine is an emergency medication, it should have been placed in the emergency trolley until when it was needed. Additionally, the presence of a nurse at the bedside would have helped Marko park only what was meant for him and leave the rest. Lastly, the manufacturers needed to make easily distinguishable syringes for atropine and heparin.
Implications Of the Adverse Event or Near-Miss for All Stakeholders
The above near-miss incident is an example of a medication error that would have harmed all the involved stakeholders, including the patient, the family, healthcare workers, the healthcare institution, and the community if it occurred. The patient would have experienced both short-term and long-term effects on the patient’s side. The short-term effects would result from antimuscarinic action and may consist of the patient feeling fatigued, tachycardic, urinary hesitance, nausea, vomiting, and loss of libido (Zhao et al., 2020). On the other hand, although 2mg atropine is recommended during administration when given by mistake, especially in the absence of an actual nerve agent, it may lead to incapacitation, failure to think correctly, and even death, especially in patients with underlying cardiac disease (Zhao et al., 2020). In this case, the patient would have died since he already had hypertension. The healthcare workers would also have been affected in the short term and in the long run. In the short term, the team handling the patient would have lost their credibility and would be termed incompetent in their duty. However, the workers would be sacked after investigations due to negligence and not being keen when handling their patients. The patient’s family would have also been harmed if the near-miss resulted in an adverse event. Since the patient was hypertensive, administering the atropine inappropriately would have resulted in the patient’s death. Lastly, the healthcare facility would also be negatively affected. First, if the information leaked to the public, they would have lost their credibility, discouraging other patients from visiting. Secondly, the incident would have resulted in lawsuits, making the hospital incur huge losses in terms of compensation. A report released by the Office of disease prevention indicates that hospitals spend approximately $ 16.4 billion annually addressing issues arising from medication errors (Jember et al., 2017). As a result, preventing near misses before they occur is critical.
When handling a patient as a team, communication is vital in preventing some errors from occurring or missing some protocols. Both the nurse, pharmacist, and physician would have actively collaborated from admission to the patient‘s discharge (Gnoni & Saleh, 2017). Doing so would have made it easier to note that an atropine box had been placed on the patient’s bedside, although it had not been used. This would have helped in it being taken from the bedside and stored appropriately. After the near-miss, different protocols were instituted. First, no patient was to be discharged from the hospital without two nurses. The role of these two nurses was to check and ascertain that the patient was only going home with what was required of them. Additionally, a policy was passed requiring that no medications are placed at a patient’s bedside.
Quality Improvement Technologies Related to The Event
With the technological changes in the modern world, the healthcare system is also benefiting from such changes. Different technologies have emerged and can be used to prevent medication errors (Hasanspahić et al., 2020). In this scenario, a computerized physician order entry would have been of benefit. Although the hospital had a comprised physician order entry before the occurrence of the incident, some of the steps in its use were often omitted hence contributing to more errors. However, with reinforcement being done, it has helped ensure that only the proper medication is given to a patient. When using this technology, it is structured so that computerization ensures that the medication’s dose, route, and frequency are noted. In this event, assuming the order was computerized, the patient would be aware that the atropine is not administered as a subcutaneous injection but intravenously (Alotaibi & Federico, 2017). As such, noting these differences would have helped prevent this near-miss event.
Different institutions have incorporated this technology and have been successful. According to a study conducted by Alotaibi & Federico (2017), a community hospital in Phoenix, Arizona, used this technology to help detect any deviations during drug prescription and administration. According to this study, using a computerized system helped the hospital detect opportunities that would prevent injury to patients at a rate of 64 per 1000 admissions (Alotaibi & Federico, 2017). Based on the Arizona Phoenix hospital findings, it is evident that using computerized physicians can be an effective strategy for preventing near-miss events from occurring in our healthcare institutions.
Relevant Metrics of The Near Miss Supporting the Need for Improvement
Before this event, this near-miss accounted for 60 per cent of all the medication errors that occur in the hospital. However, when closely analyzing, 40 per cent of the errors would be effectively prevented if the latter followed the stipulated protocols. However, because of the failure to follow simple protocols, this healthcare facility incurs costs of $ 6 billion annually. According to the Medical Care Availability and Reduction of Errors Act, all healthcare institutions need to report all near misses. A study conducted by Jember et al. (2019) indicates that improving patient safety is critical. As a result, collecting and adopting anonymous reporting and feedback would lay a foundation for healthcare institutions to conduct a careful analysis of the incident, identify underlying factors, and propose strategies to mitigate the risks.
A report released by the Institute of Medicine (IOM) indicates that approximately 400,000 medication-related injuries and near misses are preventable. However, the absence of policies or failure to follow them properly has contributed to hospitals incurring up to $ 3.5 billion yearly (Jember et al., 2018). As a result, hospitals need to look into viable strategies that can help them minimize the occurrence of these events and save on their costs.
Quality Improvement Initiatives to Prevent the Reoccurrence of The Near-Miss
My facility has adopted computerized physician order entry concerning prescribing and dispensing medications to patients. Before any nurse or pharmacist recommends a given medication to a patient, a physician must be present to confirm the order. After the dispensation, the patient must visit the physician’s room, where the order will be confirmed before the patient leaves the hospital. Following this protocol has helped ensure that a patient only goes home knowing the type of medication they are supposed to take, the dosages, and how to administer them appropriately. Additionally, the hospital developed a reporting system where when a near miss occurs, it is documented, reported, and a detailed investigation launched. The patient community is then called upon to discuss the event. Through the meetings, strategies have been developed to help reduce these errors, including modifying the ordering template for bedside medications and modifying the standard discharge procedure where all bedside medications are packed together under the supervision of a nurse upon discharge.
Near miss events occur in all healthcare institutions, and hence strategies have been adopted to help address them. One quality improvement initiative that most hospitals rely on is the development of quality reporting systems. Findings from a study conducted by Röhsig (2020) note that reporting near-miss events provides hospitals with valuable information that helps them proactively reduce errors. When near misses are reported, especially concerning medications, it lays a foundation for the missed protocol to be communicated to the relevant stakeholders and the corrective measures instituted (Röhsig et al., 2020).
Different quality improvement initiatives have been developed to help in mitigating medication errors and have been successful. Since the emergency department plays a role in preventing medication errors, task forces have been developed to help in addressing critical areas of medication errors, including allergies, high-risk medications, look-alike medications, drug storage, and management of prescriptions. During the evaluation, medication errors were noted among high-risk medications. As a result, recommendations were made regarding how these medications should be stored from the non-risky medications. Clear labels were attached to their treatment forms for patients with drug allergies to help any person managing the patient not to administer the medication unknowingly. This project kicked off in 2015 and ended in 2020. By the end of the five years, near-miss events related to medications had reduced from thirty to six per cent (Röhsig et al., 2020). My institution can prevent this error in the future by clearly labelling all medications given to patients since this would help reduce the confusion. Before releasing a patient, the medications should also be confirmed by a nurse before being allowed to leave. Confirming the type of medication by another nurse is a protocol that, when followed, can help reduce near misses to a greater extent.
In conclusion, near misses are 300 times more likely to occur than adverse events hence the need to take preventive measures. Although they do not harm patients, mitigating them before they occur helps in improving patient safety. Near misses can be easily captured through timely reporting and documentation. Doing so helps stakeholders initiate measures that will help prevent errors from occurring in the future. The interdisciplinary teams managing a patient should strive to maintain open communications since it will help note discrepancies in a patient’s treatment plan and promptly correct them.
Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient safety. Saudi medical journal, 38(12), 1173.
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Hasanspahić, N., Frančić, V., Vujičić, S., & Maglić, L. (2020). Reporting is a critical element of an effective near-miss management system in shipping. Safety, 6(4), 53.
Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). A cross-sectional study is the proportion of medication error reporting and associated factors among nurses. BMC nursing, 17(1), 1-8.
Röhsig, V., Lorenzini, E., Mutlaq, M. F. P., Maestri, R. N., de Souza, A. B., Alves, B. M., & Oliveira, D. (2020). Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study. International Journal of Risk & Safety in Medicine, 31(4), 247-258.
Zhao, C., Cai, C., Dong, Q., & Dai, H. (2020). Efficacy and safety of atropine to control myopia progression: a systematic review and meta-analysis. BMC ophthalmology, 20(1), 1-8.