NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

Adverse Event or Near-Miss Analysis

Student name 

Capella University

NURS FPX6016

Professor’s Name

Submission Date

Though strides have been made in Riverside Community Hospital’s safety culture regarding the establishment of safety-oriented technology and trained staff, system weaknesses have been revealed through the persistence of medication errors, especially those concerning the administration of insulin. Errors such as these may be attributed to the poor prescription or administration of medications. Tariq and colleagues (2024) identified the analysis and assessment of such events as a critical component in the evaluation process of system weaknesses, with the aim of precipitating improvements in quality. This work intends to focus on the assessment and analysis of the event, to devise intervention strategies to improve safety, and indicate which interventions, in the opinion of the authors, will help sustain the safety culture.

Case Scenario

One of the near-miss cases was the one at Riverside Community Hospital concerning Mr. Daniel Carter, who is a patient who has undergone a knee replacement surgery and is also a type 2 diabetes patient. One day, the night nurse’s shift ended up changed, and she reported the blood glucose as 410 mg/dL instead of its correct reading of 140 mg/dL. On this erroneous verbal communication, the day nurse was ready to give an insulin dosage of 20 units instead of the 4 units of insulin as directed.

A student nurse who was doing a chart check noticed the discrepancy and reported it to the team, which allowed for the checking and correction of the error prior to giving the insulin. This incident proved to be a valuable lesson in the inefficiencies of handoff communication, verbal reporting, and the lack of common systems to verify high-alert medications, but there was no harm to the patient.

Impact and Analysis of Near Miss

Although there were no direct injuries caused, Mr. Daniel Carter’s Riverside Community Hospital near-miss case is important to many people. The initial step of the patient assumed that he was injecting 20 units, but having not injected 4 units, he might have taken the chance of doing that. These consequences could have been a lengthy hospital stay, a prolonged hospital stay, and/or other life-threatening conditions (Story, 2023). While Mr. Carter was not harmed, the occurrence of a near-miss will and does reduce patients’ confidence in the effectiveness of a healthcare system and will dissuade them from seeking any further care. This case raised the issue of professional and emotional nursing.

There was an absence of clear communication that resulted in a night nurse increasing the nurse’s concern. This incident also indicates deviation from safe medication practice. The nurse may experience a loss of confidence and moral distress (Alhur et al., 2024). The student nurse was involved to help provide a structure for the participation of all the members of the unit to promote the ability for each to express him/herself in a manner that helps to further develop the unit members’ psychological safety.

This incident is indicative of systemic failures in reporting, handover communication failures, failures in reporting, and adherence to high alert medication procedures. This would have caused not only a financial loss to the organization, but a loss of reputation and a regulatory incident. The leadership and quality teams must understand that near misses indicate the need for change in processes, and not a blame culture. The safe administration of medication requires a range of different processes to be integrated and harmonized, which involve an array of different stakeholders, including doctors, pharmacists, and nurse educators (Alhur et al., 2024). For this to be achieved and a culture of safety for the patients to be established in the organization, the focus must be on the elimination of strict accountability for professional practice and the imperative for disciplined practice of structured handover.

Assumptions

In this analysis, it is most likely that the blood glucose reading on the EHR for Mr. Carter is correct at 140mg/dL, and the error occurred during the oral handoff and not when the blood glucose was documented. The other is that insulin is classified as a high-alert drug in the hospitals, and would have required an independent double check, which may not have taken place (Silvestre and Spector, 2023). A probable reason was the interrupted shift change that increased the pressures of fragmented communication and time. Additionally, it is likely that there was no routine use of a structured handoff tool or the formal practice of read-backs. Finally, the analysis’s common thread is the absence of a “report and be punished” policy to promote learning and enhance quality.

Root Cause Analysis of the Sequence of Events

The case involving patient Daniel Carter shows that it was a near miss at Riverside Community Hospital for Insulin Administration due to a medication administration process flaw, and the event was not due to anything the patient did. Blood glucose levels of 140 mg/dl in a patient in an actual situation should not be a concern, and Mr. Carter, in this situation, was not an obstacle to the operation. The events of the case should not be considered in an isolated manner. The events of the case began with a very busy shift change. The outgoing nurse verbally informed the incoming nurse of an erroneous glucose reading of 410 mg/dL. Based on this misinformation, the new nurse was prepared to administer an extremely high dose of insulin that was prescribed.

This situation shows that poor communication and a failure to verify a situation can place a patient in a situation of a very high safety risk, and is more concerning than the actual diagnosis the patient has. The recent literature for patient safety has shown that near misses relate to systemic flaws, human factors, and communication failures, and are not due to the lack of diligence and concern, or untimely care and poor expertise of the caregiver (Silvestre & Spector, 2023). The near-miss situation was prevented because the nursing student physically verified the electronic health record and posted correct documentation.

Missed Steps and Protocol Deviations

Mr. Daniel Carter describes an incident at Riverside Community Hospital that demonstrates the need for the incorporation of essential safety practices. This incident is an example of the need for verifying the electronic health record. In this case, the night nurse checked and documented the patient’s blood glucose, but the day nurse did not verify this and went on to prepare the insulin (Gerwer et al., 2022). There were also instances in which critical safety practices were either not cited or incorporated.

These included two-person verification of medication and handoff communication tools, e.g., SBAR. To improve medication safety and mitigate harm, some of the critical gaps that were identified at the system level must be analyzed and implemented (Rashdan et al., 2025). Additional factors included a busy shift, heavy workload, and use of verbal confirmation of medication, which compounded the risk of a medication error and the risk of communication failure.

Preventive Interprofessional Communications

Without any time for interprofessional communication, the near-miss incident for Mr. Daniel Carter could not have been avoided. Standardized handoff tools and repeating the reading of critical values, along with the pharmacist verifying the prescribed insulin, would have helped ensure the right dose was prescribed. Research shows that structured handoff tools like SBAR have a positive effect on the knowledge and clinical practice of nurses, as well as their perceptions of shift handoffs and task assignments in non-critical care (Haliq and AlShammari, 2025).

Regular cross-collaboration of teams at the end of each shift, as well as a focused effort to locate information discrepancies about patients, can lessen the burden on memory and decrease the chances of error. In order to improve patient safety, a cross-collaborative approach should be used within the nursing, medical, and pharmaceutical professions to actively look for potential errors and design ways to mitigate those.

Relevance and Knowledge Gaps

Dr. Silva mentions that miscommunication during handoffs is the major contributing factor to approximately 80% of occurrences where adverse events were reported, and where near-misses were documented. There is a lack of knowledge to comply with handoff protocols for 2-person checks, top drugs, and the impacts of an overwhelming shift. There are also barriers that inhibit the reporting and/or notifying of a near-miss to increase organizational learning. System interventions and continuous education must be implemented to maintain and improve the safety of the patient.

Quality Improvements for Risk Reduction

There are many quality improvement tools and technologies Riverside Community Hospital can adopt to help mitigate danger to patients from insulin errors. One further benefit of BCMA is its ability to dramatically decrease medication error, demonstrated in studies showing a 54% reduction in error with BCMA, and improve nurses’ safety perception (Grailey et al., 2023). The functional elements of clinical decision support (CDS) found in electronic health record (EHR) systems can assist and promote safe patient care with the provision of alerts and guidance for hyperglycemia control in the inpatient setting (Gerwer et al., 2022).

It will also increase the precision and dependability of the handoff with regard to incoming and outgoing shifts and help minimize miscommunication and/or error regarding the standing and/or ad hoc insulin orders and vital information, e.g., SBAR model (Haliq and AlShammari, 2025). More specifically, training in communication and collaboration is required to improve the inter-professional collaboration of nurses, physicians, and pharmacists (Jung and Park, 2025).

Some examples of ways the QI initiatives can be assessed based on the interventions described above are by monitoring the near-miss/medication error rate per patient day, compliance with the double-check procedure, or documenting the time lapse between error identification and error rectification to keep patients safe from harm in the future, as was the case for Mr. Daniel Carter.

Integration of Solutions in Other Institutions

The strategies that Riverside Community Hospital can implement to reduce the number of errors made during the administration of insulin are similar to those adopted by a number of hospitals across the United States. An example of this is found at Johns Hopkins Hospital, where it was reported that nurses who used a smart agent system made fewer errors compared to those who used the manual processes, which reported a 16.6% error rate (Johns Hopkins Medicine, 2021), and allowed nurses to spend less time on the tedious task of manually dosing insulin.

Another example can be found at the Mayo Clinic, which, in order to enhance the quality of care for those patients afflicted with chronic conditions, has used evidence-based care to develop a method for preventing, identifying, and rectifying errors in a timely manner, utilizing standardized EHR data, lab results, and medication administration data (Ramar et al., 2025). The frameworks outlined in the examples of the two hospitals are geared toward improving safety systems focused on error prevention. These frameworks feature safety systems with elements that are designed to quickly identify errors and implement interventions that prevent injury for patients like Mr. Daniel Carter, and prevent close calls/crosses.

Relevant Metrics Supporting Improvement

Insulin administration mistakes are unfortunately common in hospitals. They can result in long-term negative patient outcomes, such as hospital stays and patient deaths, and can instigate avoidable patient suffering and anxiety in the form of hypoglycemic episodes. The literature suggests that medication errors are a common occurrence in the hospital setting, and that the outcome of such errors is often worse than the original presenting problem, and may even be life-threatening (Ferreira et al., 2025). Mistakes that almost happen, as well as those that are recorded, are important for benchmarking patient safety systems and can be utilized in quality improvement initiatives.

In the case of Mr. Daniel Carter at Riverside Community Hospital, you need to look at the individual incident and the many possible systemic failures within the hospital, at the absence of safety technology solutions, at the lack of a standardized safety communication, and the inability to adequately resource and enforce a safety-focused approach to a medication safety system. Safety Technology solutions need to be addressed for high-risk medications in order to improve the safety and outcomes for patients.

Quality Improvement Initiative to Prevent Future Near Misses

It’s important to have a comprehensive, evidence-based, quality improvement (QI) programme that focuses on high-risk medication safety, as was the case in Mr Daniel Carter’s case, which happened in Riverside Community Hospital. In this case, the error was found when the student nurse looked into the patient’s electronic health record (EHR) on the device prior to giving the insulin, which, if not, would have caused injuries. This incident was reported as per the hospital’s report system and the interaction between the interprofessional team was debriefed to analyse the incident.

The results of research confirm the applicability of medical simulation and debriefing as a successful teaching solution to enhance clinical decisions and compliance with safety standards (Salik and Paige, 2021). Real-time surveillance needs to include near-miss reports as well as the systematized handoff protocols and the use of 2-person verification of high-alert medications. Evidence-based interventions to prevent insulin-related errors have been shown to decrease the number of errors, including barcode medication administration (BCMA), handoff communication using the SBAR method, standardizing medication verification, and simulation-based staff training.

For Riverside Community Hospital, the QI project would mean that all insulin orders must use BCMA, all shifts must use SBAR, and regular staff training on using BCMA would occur through simulation, and ongoing monitoring of BCMA use and near misses would be done to encourage long-term positive changes in patient safety.

Conflicting Perspectives

Although the effectiveness of BCMA and structured handoff tools in reducing medication errors has already been proven, the rates of utilization may vary due to technical issues and potential disruption of workflows. At Riverside Community Hospital, employees in the care environment in which the EHR is one of the facets driving the delivery of insulin are challenged in using the technologies to their full potential and maximizing the patients’ care. These are minimized by providing for the staff planning and implementation, regular training, and making changes in the workflow without major interruptions.

In this light, the effectiveness and sustainability of the QI program are established, so as to manage the balance between the evidence-based practice and the limitations of the busy hospital environment. Taking staff along in active ways supports patients’ safety and an ‘improvement culture,’ reducing the potential for unintended consequences of new safety measures that can negatively impact patients like Mr. Daniel Carter.

Conclusion

This near miss with Mr Daniel Carter shows the need for an enhanced system of controls at the level of the system with respect to the use of high-risk medication like insulin. The use of structured handoffs, BCMA, and two-person verification will minimize errors and enhance patient safety. These practices lead to success and sustainability through ongoing staff training and working with other professionals. Near misses are important to prevent in the future, and quality enhancement programs are active.

For the next (2nd) assessment of this class visit: NURS FPX 6016 Assessment 2