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

Student Name

Capella University

NURS-FPX 6016 Quality Improvement of Inter-professional Care

Prof. Name



In the medical field, medication management tends to be one of the most important parts of any procedure or treatment, and any significant error in the medication tends to become hazardous for the patient and leave a bad impression on the hospital. Medication errors continue to be one of the most significant adverse events in medical history. Researchers have deeply investigated the contributing factors that may have contributed to the medical error (EMA, 2018; Stolic et al., 2022). There has been a tremendous increase in the number of patient safety-related publications explaining how near-misses or adverse events have impacted or caused potential harm (World Health Organization, 2018).

Similarly, the World Health Organization has highlighted that one of the major causes of injury and avoidable harm in the health care system across the world is associated with medication errors, such as giving the wrong medication. Medication errors occur when inadequate medication systems and/or human factors such as weariness, bad environmental conditions, or staff shortages affect prescription, transcription, dispensing, administration, and monitoring practices (Khan & Tidman, 2022). These errors can then result in serious injury, disability, or even death. Implementing stronger medication systems and managing human factors can also prevent medication errors. Likewise, the estimated cost due to medication errors is approximately 42 billion dollars (World Health Organization, 2016).

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

The aim of the current assignment is to understand the impact of medication errors. The case under discussion was based on providing the wrong medication to a heart patient, which led to an emergency situation. Due to the error on the part of the nurse, the patient had to undergo surgery, which had a significant impact on the patient. The aim of the current analysis was to investigate the near-miss incident and the implication it had on all the stakeholders, the root cause analysis, and the action plan to combat the issue.

Implications of the Wrong Medication for All Stakeholders

It is critical to understand that the wrong medication can have serious consequences, especially in critical cases such as those involving heart patients. For example, when such medication errors occur on the patient if the health care provider is a heart patient, the consequences are severe due to the critical nature of cardiovascular health. Medication error is a long-term problem, as it may come with many consequences for all of the individuals that are directly or indirectly affected by it (Marufu,  et al., 2022). It can have an impact on many stakeholders, such as:

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

  • Patients: One of the most commonly affected stakeholders when it comes to medication errors is the patient himself. As the medication is being implemented on the patient, the direct impact will be on the patient. Heart Patients are more susceptible to the negative effects that can arise from taking the incorrect medication. The inappropriate use of medication can have negative consequences for the cardiovascular system, which may result in arrhythmias, variations in blood pressure, reduced cardiac function, or other life-threatening issues. Patients could have chest pain, difficulty breathing, lightheadedness, or even cardiac arrest as a result of the condition. Taking the incorrect prescription might make the underlying cardiac problem worse, which could lead to permanent damage or even death in the long run. Patients may experience mental discomfort, dread, and a lack of trust in the healthcare system in addition to the physical effects of the condition.
  • Healthcare provider: The next in line for the massive impact are the healthcare providers, who are technically responsible for the prescription-to-administration process of wrong medication that may have caused serious health hazards for the patient. The healthcare providers may have emotional and professional implications such as guilt, remorse, and a sense of incompetence that may impact their medical practice and affect their confidence. Also, it can lead to reputational damage, legal consequences, and disciplinary action that may result in scrutiny, the cancellation of a license, additional workload, and excessive training.

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

  • Organization: The organization where the issue has occurred also has to face the impact of the action. Accidents in which heart patients receive the wrong medication can be extremely damaging to the organization’s reputation and can erode patients’ and the community’s trust in the medical facility. It is probable that as a result of this, the number of patients may decrease, along with a loss of revenue and severe legal obligations. The penalties, sanctions, or necessary corrective actions that regulatory bodies may impose may have a detrimental impact on the organization’s ability to maintain its financial stability and continue its operations. These penalties, sanctions, and necessary corrective activities may come in the form of fines, suspensions, or other requirements. Healthcare organizations will need to make investments in the process of examining drug practices, putting safety measures in place, educating personnel, and upgrading systems in order to reduce the likelihood of errors of a similar sort occurring in the future.
  • Families and caregivers:This can be an emotionally challenging issue for caregivers and their families. They may also experience psychological stress and anxiety regarding the well-being of the patient, along with the difficulties of navigating medical care and finding the correct ways to ensure the patient’s well-being. This may also cause resentment and anger toward the healthcare system and the overall impression of the government in charge.
  • Insurance and government: both of these parties have a financial burden due to the incorrect medication as the hospitalization time increases, causing more expense and leading to more use of resources.

Root Cause Analysis of the Wrong Medication

The root cause analysis of the situation that is being discussed is based on multiple perspectives, with the aim of finding every possible loophole that might have led to the medication error in a heart patient.

  1. Prescription stage: The most significant error that might have occurred on the whole was associated with a wrong prescription, incomplete patient information, or the pharmacist’s inability to read the doctor’s prescription accurately. If the patient’s information is incomplete or missing, chances are that the prescription may be wrong as their entire history is not clearly seen.
  2. Misinterpretation of Physician Writing: Many errors occur due to the inability to read the writing of the physician or typing the wrong spellings of the formula, which may change the entire class of medication that has been prescribed.
  3. Misreading of the prescription: At times, the issue is associated with the pharmacist not being able to carefully pack the medication, thus leading to the medication error.
  4. Administration stage: The fact that the nurses or the administration staff handed over the wrong medication may become a potential cause of concern for the patient.
  5. Monitoring and follow-up stages: Lastly, the fact that the nurses or the healthcare providers failed to assess the efficacy of the medication in the monitoring or in the follow-up and continued a medication that was not beneficial for the patient

Quality Improvement Actions

The quality improvement actions allow the physicians as well as the nurses to become prepared for such issues and have a better plan to combat them in case of emergencies. Thus, to increase patient safety, the following plan can be implemented:

  • Enhance Medication Safety: Patient safety is of paramount importance, so the first step in improving medication management is to streamline the medication administration process. This can be done, for example, by using a patient entry order that sorts medications alphabetically by their formula names rather than their brand names. Other methods could be using the barcodes or identifying specific medical dispensaries where people can buy those medications.
  • Communication in Teams: Having a standardized handoff protocol would also help in establishing clear and guided communication and information exchange, which increases patient safety and the quality of care that is being provided. Similarly, promoting effective teamwork and communication among other healthcare providers, such as nurses, doctors, and pharmacists, can increase the safety of medication.
  • Patient Engagement and Education: Another way to promote medication safety and improved healthcare is by engaging patients and educating them so that they become capable of taking care of their medication and reduce the risk of error on their part. This also encourages them to take initiative and express their concern regarding medication. Having programs regarding health literacy can help in understanding the educational materials and instructions and reduce medical errors.
  • Use of technology: Electronic health records, computerized patient entry, or automated alarms can help in remembering the record and type of medication that is being utilized, allowing patients to become aware of the medication while the government has authorized access to the patient’s medical history and medication they are currently taking.

Quality Improvement Initiative.

The aim of the quality improvement initiative with respect to rescuing future adversities was designed to reduce medication errors in hospitals through the implementation of evidence-based practices and strategies.

  • The first strategy is to establish an all-rounded team. Such as having a team that consists of representatives of nursing, physicians, pharmacists, quality improvement staff, and IT members to ensure that the medication dispensing is accurate and without any error.
  • Second, conducting a baseline assessment For every issue, the most important thing is to develop a baseline assessment through reviewing reports and events associated with identifying the probability and reasons for a near miss.
  • Then, having set goals and clear expectations makes it more approachable for the patient as well as the healthcare providers.
  • Then, having strict policies regarding incidence and a clear action plan can help every individual involved be sure of the consequences of their mistake and ensure a quality hospital.
  • Similarly, having computerized prescriptions and standardized medication allotment protocols can also help maintain quality and reduce adverse events.
  • Education and training to develop comprehensive education programs for providing safe medication practice and error prevention, along with clear communication, feedback, and honest service reviews.
  • Lastly, feedback, continuous improvement, and outcome evaluation may help in providing information and increasing the chances of improvement.


In conclusion, medication error prevention and quality improvement initiatives increase patient safety and reduce adverse events and near misses. A multidisciplinary team, baseline evaluation, explicit targets, and evidence-based initiatives can help healthcare organizations improve pharmaceutical safety. Standardization and simplification of medication processes, fostering a reporting and learning culture, continuous monitoring and evaluation, and healthcare team collaboration and communication are key components of the initiative.


EMA. (2018, September 17). Medication errors. European Medicines Agency.

Khan, A., & Tidman, M. M. (2022). Causes of medication error in nursing. Journal of Medical Research and Health Sciences5(1), 1753-1764.

Marufu, T. C., Bower, R., Hendron, E., & Manning, J. C. (2022). Nursing interventions to reduce medication errors in paediatrics and neonates: Systematic review and meta-analysis. Journal of Pediatric Nursing62, e139-e147.

Stolic, S., Ng, L., Southern, J., & Sheridan, G. (2022). Medication errors by nursing students on clinical practice: An integrative review. Nurse Education Today, 105325.

World Health Organization. (2018). Medication Without Harm.

World Health Organization. (2016). Medication Errors Technical Series on Safer Primary Care.

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