NURS FPX 6016 Assessment 1 Adverse Event or Near
NURS FPX 6016 Assessment 1 Adverse Event or Near
The culture of safety in healthcare institutions is upheld, yet the events and near misses are negative, still occurring despite the introduction of technology, protocols, and trained staff. Medication errors are the most frequent source of patient harm, which inflicted in a variety of phases of the care process, starting with the prescription and ending with the administration of the drugs (Tariq et al., 2024).
These events can be critically analysed to provide valuable information regarding systemic vulnerabilities and opportunities on quality improvement (QI). The review examines a near miss involving the insulin administration at one of the American hospitals, the implications of this situation to the stakeholders, a root cause analysis, QI activities and technologies, and outlines an evidence-based initiative to prevent future errors.
Case Scenario
The case of a postoperative diabetic patient, Mr. Robert Hall, after knee replacement surgery at St. Marys Medical Center occurred as a near miss. The night nurse was giving the patient a verbal order to increase her blood glucose to 410 mg/dL and not the right 140mg/dl during one of her shifts since the shift was changing over to a busy day. On this misinterpretation the day nurse was even prepared to give the insulin 20 units rather than the 4 ordered.
It was noticed by a student nurse reading the electronic health record and this resulted in verification unless it was administered. No harm was caused to the patient and it was a close call. The incident also demonstrated vulnerabilities in the communication of handoffs, compliance with protocols, and verifications and pointed to the need to introduce facilitated, technology-based handoffs and standardized double-checks to avoid medication errors with high- alertness and enhance patient safety.
Impact and Analysis of Near Miss
The insulin near miss at St. Mary’s Medical Center has far reaching consequences to several stakeholders. To the interprofessional team, the incident showed gaps in communication, checking, and following procedures and the staff began to reflect on the issue of handoff practices and responsibility. Haliq and AlShammari. (2025) reported important communication failures when there is a paramedic and nurse handover in an emergency care.
Responsibilities
Collaborative practice teams are the best in maximizing person-centered care provision and improve patient and system outcomes (McLaney et al., 2022). Nurses are expected to provide proper assessment, reporting, and dominion checking to high-alert medications. Doctors must take care of proper orders and reports of patients. Pharmacists help in dose checking and safety warning.
Preventive Measures
Prevention needs to be formalized with handoff tools such as situation, background, assessment, recommendation (SBAR) or the two-check approach necessary when administering high-risk medications and usage of electronic health records with alerts about dose discrepancies. It has also been demonstrated that the adoption of SBAR and mind map communication modalities reduces the frequency of defects, the number of adverse events, and nursing satisfaction (Haliq and AlShammari, 2025).
There is a need to establish education programs that are more concerned with safe administration of insulin, management of fatigue, and effective interprofessional communication. Unit management and the quality improvement committee have the duty to enact policies, ensure compliance, and audit near-miss reporting to continuously improve patient safety practice.
Assumptions
This analysis presumes that personnel were clinically capable but limited by heavy workload, environmental distractions, and variable handoff practice. It also presumes that the near miss was recognized as such through vigilance by a nursing student, as opposed to an inherent fail-safe within the system. Near misses and errors happened because students did not always verify patient identification, confirm allergy status, or use the rights of medication administration (Silvestre & Spector, 2023).
NURS FPX 6016 Assessment 1
These assumptions put the blame on systemic solutions rather than on an individual staff. This incident was likely to impact practice among the staff members and result in increased verification procedures, improved documentation, and more attention to interprofessional standards of communication.
Root Cause Analysis of Sequence of Events
Missed Steps and Protocol Deviations
There were some important processes that were overlooked, and this contributed to the near miss. The EHR was not properly verified, and documented blood glucose levels by a night nurse. The day nurse failed to independently confirm the present level of glucose in the patient before filling the insulin. Two-person medication verifications and standardized handoff technology, including SBAR, were also not being consistently applied.
It is essential that the identification of those factors that lead to errors with medication be done to enhance patient safety (Rashdan et al., 2025). Some of the contributing factors were environmental distractions, heavy workload, and verbal reporting as opposed to electronic confirmation.
Preventive Interprofessional Communications
The occurrence would have been avoided by effective interprofessional communication. Proper insulin dosing would have been achieved by the use of standardized handoff tools, read-back of critical values, and shared verification with the pharmacists.
It has been concluded that structured tool training, the SBAR type, significantly improves the knowledge, practice, and perceptions of nurses on the topic of shift handoff communication in noncritical departments (Haliq and AlShammari, 2025). Frequent team discussions at shift change and explicit commenting of differences would reduce the use of memory and decrease risk. Nurses, physicians and pharmacists should communicate effectively to identify errors before being administered.
Preventability and Knowledge Gaps
This near miss was extremely preventable through compliance with current protocols and implementation of technology-assisted safety interventions.
Integration of Solutions in Other Institutions
Other U.S. institutions have implemented similar solutions with success. Mayo Clinic uses structured EHR data, including lab results and medication administration history, to monitor compliance with evidence-based care protocols for chronic diseases (Ramar et al., 2025). These interventions focus on system changes over individual fault and show quantifiable improvement in patient safety.
Quality Improvement Initiative to Prevent Future Near Misses
The incident reporting system indicated the incident and debriefed the interprofessional team. The medical simulation includes debriefing since its beginning, and the advantages of the idea have strong grounds in instructional theory (Salik and Paige, 2021). Ongoing observation entailed the observance of near-miss reports and the focus on adherence to handoff procedures and performing two checks.
Various insulin-related error prevention interventions are backed up by research, such as BCMA, SBAR, medication verification, and staff training with the help of simulation. The reason behind the success of these programs is that they standardize the work procedures, reduce dependence on memory, and improve the opportunity to detect mistakes before any damage is done. The implementation at St. Mary would include the mandatory use of BCMA when placing insulin orders, SBAR during shift handoffs, staff training in simulation, and continuous monitoring of observance of protocols and reporting near-misses.
NURS FPX 6016 Assessment 1 References
- https://doi.org/10.1016/j.ijnurstu.2025.105074
- https://doi.org/10.1007/s11892-022-01481-0
- https://doi.org/10.1186/s12912-025-03286-4
- https://www.hopkinsmedicine.org/news/newsroom/news-releases/2021/05/research-story-tip-new-automated-insulin-infusion-system-may-potentially-reduce-medical-errors-improve-care
- https://doi.org/10.1371/journal.pone.0319483
- https://journals.sagepub.com/doi/full/10.1177/08404704211063584