Adverse Event Or Near Miss Analysis In Acute Care Hospitals
Adverse Event or Near Miss Analysis
In the early 2000’s New Jersey implemented a Patient Safety Reporting System that promoted confidential reporting to the Department of Health of adverse events and root cause analysis with the goal of making patient safety a priority throughout the state’s hospitals (State of New Jersey Department of Health, 2017). Adverse events are preventable within acute care hospitals and are inclusive of medication errors, pressure-ulcers, falls, suicide or attempted suicide in a facility, and numerous surgical mishaps including the wrong patient, wrong procedure, wrong site, intraoperative or postoperative event or death. The adverse event that we will dissect and recommend strategies for prevention include a medication …show more content…
The patient arrived with a systolic blood pressure in the low 60’s and was administered three liters IVF bolus before getting the systolic blood pressure to 90 mm Hg. Again, the patient was administered IV morphine 8mg for pain and she subsequently became bradycardic and complained of feeling lightheaded. Atropine was ordered on standby and aggressive IVF hydration was continued. A CT scan of the abdomen and pelvis was performed and demonstrated a blocked left ureter with hydronephrosis. A STAT Urology consult was performed and the physician documented Stein Strasse following the lithotripsy. The patient was admitted and subsequently underwent an emergent ureteroscopy, a retrograde pyelogram, and ureteral stenting. The Emergency Department physician additionally asked the ED nurse during the change of shift to list morphine as an allergy into the electronic record due to the …show more content…
Paying attention to and documenting a patient baseline is imperative to recognize any changes in one’s condition. Munroe, Curtis, Murphy, Strachan, & Buckley (2015) noted that although the Emergency Department could be challenging with an influx of various types patients and medical issues, the need for accurate and timely assessment was instrumental in thwarting an adverse event.
The first missed step was not acknowledging the patient’s complaint of increased pain following the lithotripsy at the first ED visit with a reported sensitivity to narcotics. The physician failed to order any radiological studies to assess the patient’s kidney or kidney function further. Had a study been performed could the patient have been treated earlier instead of representing to the Emergency Department with additional stress, cost, and emergent surgery. The nurse failed to question the physician regarding the initial morphine dosage with a reported narcotic sensitivity. The nurse failed to take additional vital signs or assessment following the patient’s persistence of symptoms and failed to report them to the ED physician despite the discharge order. The nurse dismissed the complaints, placing the patient’s safety at
In the early 2000’s New Jersey implemented a Patient Safety Reporting System that promoted confidential reporting to the Department of Health of adverse events and root cause analysis with the goal of making patient safety a priority throughout the state’s hospitals (State of New Jersey Department of Health, 2017). Adverse events are preventable within acute care hospitals and are inclusive of medication errors, pressure-ulcers, falls, suicide or attempted suicide in a facility, and numerous surgical mishaps including the wrong patient, wrong procedure, wrong site, intraoperative or postoperative event or death. The adverse event that we will dissect and recommend strategies for prevention include a medication …show more content…
The patient arrived with a systolic blood pressure in the low 60’s and was administered three liters IVF bolus before getting the systolic blood pressure to 90 mm Hg. Again, the patient was administered IV morphine 8mg for pain and she subsequently became bradycardic and complained of feeling lightheaded. Atropine was ordered on standby and aggressive IVF hydration was continued. A CT scan of the abdomen and pelvis was performed and demonstrated a blocked left ureter with hydronephrosis. A STAT Urology consult was performed and the physician documented Stein Strasse following the lithotripsy. The patient was admitted and subsequently underwent an emergent ureteroscopy, a retrograde pyelogram, and ureteral stenting. The Emergency Department physician additionally asked the ED nurse during the change of shift to list morphine as an allergy into the electronic record due to the …show more content…
Paying attention to and documenting a patient baseline is imperative to recognize any changes in one’s condition. Munroe, Curtis, Murphy, Strachan, & Buckley (2015) noted that although the Emergency Department could be challenging with an influx of various types patients and medical issues, the need for accurate and timely assessment was instrumental in thwarting an adverse event.
The first missed step was not acknowledging the patient’s complaint of increased pain following the lithotripsy at the first ED visit with a reported sensitivity to narcotics. The physician failed to order any radiological studies to assess the patient’s kidney or kidney function further. Had a study been performed could the patient have been treated earlier instead of representing to the Emergency Department with additional stress, cost, and emergent surgery. The nurse failed to question the physician regarding the initial morphine dosage with a reported narcotic sensitivity. The nurse failed to take additional vital signs or assessment following the patient’s persistence of symptoms and failed to report them to the ED physician despite the discharge order. The nurse dismissed the complaints, placing the patient’s safety at