MSN-FP6016: Adverse Event or Near Miss Analysis
Adverse Event or Near Miss Analysis
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Introduction
The healthcare sector is a challenging field of work where the nurses and physicians must observe high degrees of professionalism. Minimal errors in the nursing practice can result in severe damages to the patient and, in extreme cases, irreversible health implications. The nursing code of ethics recommends that the professionals exercise a high level of work principles to ensure the patients' quality and safety under their care. The nurses and clinical officers take an oath that binds them to the practice and compels them to always promote quality health. The principles of work in the field guide the practicians on observing professionalism and being assured of the best outcome inpatient care. The minimal errors experienced in practice often threaten the patients' lives as they develop complications caused by the medical staff and not the underlying condition that brought them to the hospital.
Also Read: Best Online Nursing Care Plan Help For Students
Evaluation of missed steps and protocol deviation
Nurses operating in intensive care units must ensure the patients are safe and free from any possible harm. Intensive care requires the nurses to be vigilant and observe every form of caution while taking care of them. A nurse failed to raise the bed rails as recommended of them after every visit. The nurse had finished feeding critically ill patients and followed every step to ensure the patient as well. Unfortunately, she forgot to raise the best side rails, which prevent the patient from falling. When the nurse left to check on other patients as obligated to shift, the patient tried to move and experienced a severe fall. The patient endured injuries and broke her arm in the process. The case indicates a scenario where a nurse failed to follow protocol to ensure the patient was safe from the bed position (Ghooi, Bhosale, Wadhwani, Divate & Divate, 2016). Many questions were raised following the incident. The patients' family raised a suit terming the event as carelessness on the part of the staff. The patient endured other injuries and complications apart from the specific condition that brought him to seek medical attention at the facility.
The implications of adverse events
The events following the patient’s broken arm were critical to the nursing profession. The nurses are always reminded to ensure the patients are safe before they can leave to the nest client. When administering medication or attending to a patient in anyways, the bed rails are always adjusted to give room for the health practitioner to easily access the patient. The context makes it difficult to come to terms with the idea that a bed rail was not adjusted back to its right position to enhance the patient's safety. The case was ruled as carelessness on the part of the nurse attending to the patient. The patient endured other injuries that were not there when he was brought in for treatment at the facility. The nurse failed to follow protocol, and the incident forced her to endure the punishment from the hospital administration. The nurse faced disciplinary charges as the patient and his family sued her for negligence and poor patient attendance in critical condition. The situation resulted in an urgent convention of the nurses of their shifts to train and educate them on the important safety measures they need to observe while handling patients in the facility. The part of adjusting the bed rails is always stated in the safety notes, especially when dealing with patients in critical conditions or the elderly who are vulnerable to fall.
Quality improvement technologies
Technology has come to enhance medical facilities and operations. The intranet of things in the medical setting helps eliminate the errors in the medical setting related to human error and negligence. The hospital beds are connected to system software that allows nurses to adjust the patient beds from a remote location. The patient can adjust the bed and bed rails from the button installed on the bedside (Mohamed, 2019). Simultaneously, a nurse can adjust the bed or its rail from a remote location using the connected hospital tablets. The system software is also designed to remind a nurse that the bed rails are not adjusted to the right position. The warning alert on the system identifies the patient at risk, the room number, and points the dangers of the issue.
The technology improvement technology has been adopted in various hea