Nursing Leadership: Adverse Event or Near-Miss Analysis

Adverse Event or Near-Miss Analysis
Author’s Name
Institutional Affiliation
Course Code and Name
Professor’s Name
Date
Adverse Event or Near-Miss Analysis
In a healthcare system, patient identity plays a significant role in the provision of quality medical services and patient safety. Currently, many hospitals have implemented electronic health records (EHRs) to facilitate the collection, storage, analysis, and retrieval of patients’ medical data when the need arises. On that note, the adverse or near-miss event that this paper emphasizes is patient misidentification. Patient misidentification can occur due to a mismatch or keeping incomplete records. When this adverse event occurs, a patient might be linked to a wrong record during data collection or registration. Database queries might also generate duplicate patient records. In addition, when staff work under pressure, errors might occur during data entry. A miscommunication between various hospital departments might create a gap that can adversely lead to missing patient details. Specifically, the paper analyzes patient misidentification using a root cause analysis and recommends appropriate quality improvement technologies or actions that can be implemented to prevent such near-miss events in the future.
Implications of the Adverse or Near-Miss Event for All Stakeholders
Patient misidentification has adverse impacts on all stakeholders, the primary ones being the patients and healthcare providers. Based on the World Health Organization (WHO), the failure of accurate patient identification has severe consequences and is one of the adverse events that affect patient safety negatively. Abraham et al. (2021) conducted a study focusing on common patient misidentification cases in perioperative care. They studied 293 incidents and found out that numerous cases of patient misidentification occur due to administrative issues, missing wristbands, involving patient files in wrong records, and wrong labeling (Abraham et al., 2021). When a patient misidentification occurs, patients are adversely affected since they might receive the wrong medical services or medications. The other stakeholder influenced by this adverse event is healthcare providers. The doctors who initiate treatment procedures for misidentified patients might fall into problems, particularly when sued by the patients. Nurses can also be affected by legal issues due to providing inappropriate care to patients in cases of misidentification. Another stakeholder affected by patient misidentification is hospitals. Hospitals can also be sued for not taking the respective measures to ensure that patients’ records are kept well and aligned with the right individuals. When it comes to errors in the electronic medical records, such as database query problems or hacking, the information and technology department is the other stakeholder that can be affected due to the failure to identify and report such technical issues that might lead to the mix-ups of the patient data.
Using a Root Cause Analysis to Analyze Missed Steps, Sequence of Events, or Protocol Deviations
Patient misidentification is a prevalent problem in both outpatient and inpatient hospitals. The most common adverse event occurs when medical treatment procedures or medications are given to the wrong patient due to patient misidentification (Kulju et al., 2022). In this scenario, the individual uses a root cause analysis to depict the sequence of events that occurred leading to patient misidentification. Let’s assume the name of the patient involved to be Jason Klein. On 2nd September 2023, Klein visited a hospital with minor head injuries from an accident. During registration, the receptionist checked him in to see the doctor immediately such that he did not have to wait in the queue like other patients. The doctor reiterated that Klein should be booked in for emergency treatment since he had a condition known as hereditary hemolytic anemia. When Klein had that name, he hesitated and asked the doctor how he got that information. The doctor responded that Klein’s medical history from the EHR system revealed this data. Klein denied it, which led to medical tests conducted to confirm that the patient was right. The primary problems that remained were how that medical data was entered into Klein’s profile and who did it. After Klein received appropriate treatments for the head injuries, he had to go to another hospital from where it appeared that the data was input so that it could be removed. For sure, this incident would have had more adverse consequences if Klein had been taken to the hospital unconscious, making the doctors use the incorrect medical data obtained from the EHR system. Klein’s diagnostic misidentification occurred due to an error when entering his medical data. The healthcare provider who added the wrong medical information to Klein’s profile might have confused him with another patient with the same name. The primary potential gaps that might improve patient identification are the provision of proper training on using EHRs and tracking of patients’ records appropriately to ensure that no confusion occurs when adding more medical information to the already existing profiles.
Quality Improvement (QI) Technologies/Actions Required to Decrease the Risk and Increase Patient Safety
The prevalence of patient misidentification can be decreased by using QI technologies or actions to improve patient safety. In particular, EHR systems were introduced to make it easier for healthcare providers to gather, store, and retrieve patient data to promote the effectiveness of treatment procedures and increase patient safety. Patient identification should be a reliable process that facilitates providing healthcare services to the right individuals (De Rezende, Melleiro, & Shimoda, 2019). In other words, it involves matching medical services to people who need them. In that light, the first QI technology that can be used is digital wristbands for admitted patients. When patients are admitted to a hospital, they should be given digital wristbands for proper...