Nursing Leadership: Adverse Event or Near-Miss Analysis

Adverse Event or Near-Miss Analysis
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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...