Adverse Event or Near-Miss Analysis

Prepare an analysis (5-7 pages) of an adverse event or a near miss from your professional nursing experience and outline a QI initiative that would address it.


Adverse Event: Chemotherapeutic Overdose

Numerous adverse occurrences or near misses occur in various healthcare settings. As a result, the institutions ultimately must select the most effective methods of mitigating and limiting the risks. Adverse occurrences are one of the most serious global health issues because they typically have a negative influence on patient safety and treatment quality. As a result, adverse events are damages caused by inadequate medical care rather than the patient’s underlying condition. The primary goal of adverse event analysis is to uncover primary causes and underlying system difficulties, as well as to give recommendations for change to avoid such accidents in the future. The steps in adverse events analysis include event reporting and documentation, event investigation, root cause analysis, and corrective action execution. The aim of this paper is to analyze a chemotherapeutic overdose adverse event that occurred in a hospital and provide the best recommendations for preventing similar incidents from occurring in the future.

Prepare A Comprehensive Analysis Of An Adverse Event Or A Near Miss From Your Professional Nursing Experience That You Or A Peer Experienced

During my medical surgical placement in the oncology clinic, a 49-year-old male and a 17-month-old male, both had a diagnosis of bone cancer. The 17-month-old patient went by the name Oscar Thompson Williams, and the 49-year-old went by the name William Thompson. A nurse intern doing her first day at the oncology center was working together with a 59-year-old nurse who had 18 years of experience as an oncology nurse and was awaiting terminal leave in 2 months. The elderly nurse, as noted, often complained of long hours of working and back pain and did see an extra hand of a fresh graduate intern as an opportunity to be relieved of workload. During the 9 am medication, the chemotherapy medication came already prepared and the elderly nurse ordered the nurse intern to administer the chemo to Thompson William. The nurse intern, in turn, went to the 17-month-old and inquired from his mother whether he was William Thompson, and she agreed. The medication was meant to be for Thompson William, the 49-year-old patient but was administered to the 17-month-old baby. The baby developed symptoms of myocardial infarction and kidney failure and was immediately taken to ICU for receiving chemotherapeutic overdose.

A chemotherapeutic overdose adverse event can occur for a variety of causes, including incorrect pharmaceutical delivery, wrong dosage, and medication interaction. An overdose can cause mild to severe symptoms such as nausea, vomiting, mouth sores, hair loss, exhaustion, decreased appetite, and abnormalities in blood counts (Ingrand et al., 2020). In these situations, timely and proper actions are critical to preventing further injury to the patient. The first step would be to cease administering the drug immediately and notify the healthcare professional. Vital signs should be watched, and therapies such as symptom management drugs and blood transfusions may be required. It is also critical to do a complete patient evaluation and document all symptoms, treatments, and reactions to interventions. This information can help the healthcare professional choose the best course of action and make necessary adjustments to the patient’s treatment plan.

Comprehensive Analysis: Medication Error

  • Reporting and Documentation: A nurse reported a medication mistake after observing the wrong drug being given to the wrong patient. The event was notified to the nurse manager and noted in the patient’s medical record.
  • Investigation: The investigating team included an oncologist, a nurse manager, a pharmacist, and a quality assurance specialist. The team went through the chemo administration record, spoke with the nurse who made a mistake and the patient’s doctor and acquired any other information pertinent to the occurrence.
  • Root Cause Analysis: The error was caused by the similarity in the names of the prescriptions, the nurse’s preoccupation during medication administration, and the lack of a second check by another nurse.
  • Corrective Steps: To avoid such events in the future, the accompanying corrective actions were implemented:
  1. Providing extra drug administration and mistake prevention education and instruction to nurses.
  2. Adding a second check by another nurse to the medication administration process.
  3. To reduce confusion, a color-coding system for medication packaging should be implemented.
  • Follow-up: The team analyzed the process and followed up on the execution of the corrective steps to ensure that the changes were sustained over time.

Analyze The Implications Of The Adverse Event Or Near Miss For All Stakeholders

Stakeholders encourage collaborative interaction among them and have an impact on an organization by seeking care, planning, providing, or evaluating it. Patients, family members, physicians, clinicians, researchers, and policymakers are examples of key stakeholders that will be implicated by the chemotherapeutic overdose. The adverse occurrence of medication mistakes had numerous consequences for all stakeholders. The patient is the first stakeholder that is affected by the adverse event. Because the improper medicine was delivered, the patient’s safety was jeopardized. This emphasizes the importance of ensuring that patients receive the appropriate medications to avoid harm through the right patient, age, drug, time, and dosage (Holland et al., 2020).

The nurse who made the mistake could have faced disciplinary measures and had their professional reputation harmed. Furthermore, the nurse may have felt guilty and ashamed for making the error. The Healthcare organization will also be impacted by the adverse event of medication error as the patient suffered adverse effects from the incorrect medication. The healthcare organization could have faced legal consequences (Holland et al., 2020). Furthermore, the incident could have harmed the organization’s reputation, potentially leading to litigation. Society and family are also stakeholders that can be affected by a medication errors. Adverse incident emphasizes the importance of greater safety measures in the healthcare system to prevent pharmaceutical mistakes. It also emphasizes the significance of proper pharmaceutical labeling and storage to avoid similar accidents. The risk of injury to patients can be lowered by adopting suitable processes and systems to prevent pharmaceutical mistakes.

Analyze The Sequence Of Events, Missed Steps, Or Protocol Deviations Related To The Adverse Event Or Near Miss Using A Root Cause Analysis

A probable sequence of events, omitted steps, and protocol deviations connected to a chemotherapy drug error involves the nurse, the intern nurse, and the institution protocol. The elderly nurse made the mistake of not introducing and orienting the intern nurse on the protocols of the hospitals and different rooms to familiarize the intern with the different rooms and rules. The nurse intern further failed to show up on time, take the handing over morning report and familiarize herself with the patients. In addition, she did not employ the 5 Rs of drug medication, whereby she omitted to call out the patient by their 3 names and further check and confirm with their wrist band. She failed to apply the right patient rule. Miscommunication is also a probable sequence of events that leads to medication errors. The elderly nurse did not mention to the new nurse that there were two patients with matching names.

Standard Operating Procedures are one of the failed and missed protocols that the hospital may have failed to apply because there was no clear and coherent standard process for all elements of medicine delivery, including prescription, preparation, and administration (Rodziewicz et al., 2022). Another failed procedure is the failure to implement a double-checking routine for all high-risk medications, such as chemotherapy treatments, to verify dosage and medication selection accuracy. Furthermore, to avoid mistakes, institutions should ensure that all prescriptions are reconciled at every transition of care, such as admission, transfer, and discharge (Rodziewicz et al., 2022). It was important for the hospital to create a system for reporting and documenting adverse occurrences, such as prescription mistakes, to discover patterns and prevent such situations in the future. Healthcare organizations may limit the risk of medication mistakes and guarantee that patients receive safe and effective care by adopting these practices.

Evaluate QI Actions Or Technologies Related To The Event That Is Required To Reduce Risk And Increase Patient Safety. Evaluate How Other Institutions Integrated Solutions To Prevent These Types Of Events

QI initiatives or technologies linked to pharmaceutical mistakes and promoting patient safety can be undertaken in steps. The first step is to examine the existing situation: Conduct an in-depth evaluation of the present medicine administration processes, including SOPs, training, and technology use, and determine high-risk areas. Identify high-risk locations for pharmaceutical mistakes, such as chemotherapy drug preparation and delivery (Rodziewicz et al., 2022). This will help reduce the probability of medication errors. Best practices should be researched for best practices for medication administration, such as the use of technology and other solutions that have proven to be effective in decreasing drug mistakes, in addition to assessing technology possibilities such as electronic prescription systems, barcode drug administration systems, and computerized provider order input systems to decrease the risk of pharmaceutical mistakes (Rodziewicz et al., 2022).

To decrease the risk of pharmaceutical mistakes, it is necessary to implement the most appropriate solutions, such as technology or process modifications. This will lead to monitoring and evaluation of solution implementation to verify that it is effective in lowering the risk of medication mistakes and boosting patient safety. To reduce pharmaceutical mistakes, some institutions have incorporated technologies such as barcode drug delivery systems and computerized prescribing systems (Naidu & Alicia, 2019). These methods have proved successful in decreasing pharmaceutical mistakes by enhancing medicine delivery accuracy and efficiency and lowering the likelihood of transcribing errors.

Incorporate Relevant Metrics Of The Adverse Event Or Near Miss To Support The Need For Improvement.

Metrics that are relevant to pharmaceutical mistakes and can be utilized to highlight the need for change. Among the measures that may be utilized are (Tariq et al., 2022):

  • The number of medication mistakes per the dosage provided can be used to calculate the overall error rate and highlight areas for improvement.
  • The number of adverse events associated with pharmaceutical mistakes can be used to determine the impact of the errors on patient safety.
  • A root cause analysis may be used to discover areas for improvement and establish the underlying reasons for medication mistakes.

Integrating these metrics allows healthcare organizations to give evidence-based justification for the need for change while also demonstrating the effectiveness of their QI programs (Tariq et al., 2022). The metrics may also be used to assess the efficacy of the solutions put in place to prevent pharmaceutical mistakes and near misses, as well as to suggest areas for further development.

Outline a QI Initiative To Prevent A Future Adverse Event

A quality improvement project to prevent future adverse events due to pharmaceutical mistakes might include discovering the underlying reasons for the medication errors and performing a root cause analysis, creating a detailed QI strategy based on the root cause analysis results, including specific targets and methods for improvement. Again, to limit the risk of pharmaceutical mistakes, institutions should implement best practices for medication administration, such as the use of barcode drug delivery systems, electronic prescription systems, and computerized provider order input systems, as well as providing continual training on drug administration methods and best practices (Rodziewicz et al., 2022).

To summarize, pharmaceutical mistakes are critical problems in healthcare that can have substantial consequences for patient safety. Medical institutions may minimize the risk of adverse events and promote patient safety by doing root cause analysis, implementing best practices, educating personnel, evaluating progress, and sharing best practices. Integrating relevant metrics can give evidence-based support for the need for change while demonstrating the efficacy of QI activities. A thorough and continuing QI strategy is critical for reducing pharmaceutical mistakes and providing patients with safe, effective, and high-quality treatment.


Holland, T. J., Penm, J., Johnson, J., Sarantou, M., & Chaar, B. B. (2020). Stakeholders’ perceptions of factors influencing the use of take-home-naloxone. Pharmacy (Basel, Switzerland)8(4), 232.

Ingrand, I., Defossez, G., Lafay-Chebassier, C., Chavant, F., Ferru, A., Ingrand, P., & Pérault-Pochat, M.-C. (2020). Serious adverse effects occurring after chemotherapy: A general cancer registry-based incidence survey. British Journal of Clinical Pharmacology86(4), 711–722.

Naidu, M., & Alicia, Y. L. Y. (2019). Impact of bar-code medication administration and electronic medication administration record system in clinical practice for an effective medication administration process. Health11(05), 511–526.

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical error reduction and prevention. StatPearls Publishing.

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2022). Medication dispensing errors and prevention. StatPearls Publishing.

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