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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 Date Introduction  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 NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis 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. 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: 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. Conclusion  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. References  EMA. (2018, September 17). Medication errors. European Medicines Agency. https://www.ema.europa.eu/en/human-regulatory/post-authorisation/pharmacovigilance/medication-errors Khan, A., & Tidman, M. M. (2022). Causes of medication error in nursing. Journal of Medical Research and Health Sciences, 5(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 Nursing, 62, e139-e147. https://doi.org/10.1016/j.pedn.2021.08.024 Stolic, S., Ng, L., Southern, J., & Sheridan, G. (2022). Medication errors by nursing students on clinical practice: An integrative review. Nurse Education Today, 105325. https://doi.org/10.1016/j.nedt.2022.105325 World Health Organization. (2018). Medication Without Harm. Www.who.int. https://www.who.int/initiatives/medication-without-harm World Health Organization. (2016). Medication Errors Technical Series on Safer Primary Care. https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis