Managing Near-Miss Events

Subject: Health Care
Type: Profile Essay
Pages: 3
Word count: 752
Topics: Nursing, Ethics

Nurses encounter near miss events in their line of duty. These near-miss events are undesired and should work towards ensuring that the nurse remains vigilant in service delivery. Avoiding near miss events helps provide quality service to patients. My near miss story involves a patient under my care who was scheduled for Coumadin. Coumadin is a medication that helps prevents blood clots. To administer this medication, you are supposed to draw the patient’s blood every day. This routine had been skipped on this day because the patient had been taking his medication for a long time. Her blood had been drawn for lab analysis every day, and the results had been consistent. This led the doctor to skip that particular day’s blood work. My gut feelings were against ignoring routine procedure that required me to draw the patient’s blood for analysis. This was despite the results showing a consistency for a long time. The doctor ordered that medication is administered with no regard to the set routine. I made the doctor aware that I was not comfortable with the disregard for procedure and he told me that the medication was going to be late because the lab work was going to take some time. I decided to follow procedure. The results came back with a 7.8 reading which is almost three times the normal level. Procedure dictates that administration of medication should not take place if the reading is above 2.9. My shift had already ended so I was not there, but the doctor ran the test again for confirmation. I am told he even looked for me, but I had left for the night.

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Nurses need to avoid near misses because they put the quality of healthcare at risk. Nurses can prevent near misses by practicing proper time management. The second priority in time management requires that a nurse partakes in activities that reduce risk in patients (Kelly, 2002, p. 429). Providing timely medication includes following all procedures required. Using ethical knowing, a nurse can decide to present the patient with the right care by following all the needed procedures to ensure a patient’s safety. This involves overlooking previous data that might lead to the disregard in the standard procedure. The reliance of previous data almost brought harm to a patient.

Nurses can prevent near miss events by taking sentinel event reviews more seriously. Sentinel events is an unexpected occurrence that involves the death or serious injury of the patient. Such events may occur due to a disregard for standard procedure. In this case, a Sentinel review is written with immediate effect to help prevent future mistakes (Kelly, 2002, p. 485). Reviewing the processes required to administer Coumadin and marking the failed steps and the risks involved will work better in preventing such an occurrence from happening. The patient would have suffered untold injuries had the medication been administered using the right procedure.

The nurse can prevent near miss events by using measurement as their guide in service delivery. Nurses need to collect and report measures at different levels in an organization. These measures include patient satisfaction and organization performance measures (Kelly, 2002, p. 485). By collecting such measures, nurses ensure that service delivery is at an optimum. Patient satisfaction measures ensure that the client gets the care they paid for. A nurse ensures that this care is provided for by following all procedural steps when providing care. The data collected in such measures can be used to create a balanced scorecard that helps determine whether the organization’s priorities are met. One of the organization’s priority should be providing quality healthcare to its patients. A nurse should follow such measures to ensure that the aesthetic quality of nursing is upheld by providing untainted service.

Using ethical knowing, a nurse will ensure that he or she provides the patient with the best care available. A nurse is tasked with providing quality care for their patients. Failing to observe all steps in the administration of a drug was a near miss event that should be avoided at all costs. This also applies to cases where a doctor overrules certain procedures for saving time or avoiding in the late administration of medicine. Striving to provide quality care will ensure that the patient gets value for their money. Taking great care of standard procedure also prevents sentinel events that could lead to death or serious injury to the patient. Taking these steps into account will ensure that nurses avoid near miss events in the future.

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  1. Kelly, P. (2012). “Time management and setting patient care priorities.” In Nursing leadership & management. Clifton Park, NY: Delmar, Cengage Learning.
  2. Kelly, P. (2012). “Managing outcomes using an organizational quality improvement model.” In Nursing leadership & management. Clifton Park, NY: Delmar, Cengage Learning.
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