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

Capella University
NURS-FPX6016
Professor’s Name
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NURS FPX 6016 Assessment 1

2. Adverse Event or Near-Miss Analysis
Preventable adverse events remain a leading cause of morbidity and mortality in healthcare,
contributing to over 250,000 patient deaths annually in the United States (Skelly et al., 2023).
Common preventable incidents include medication errors, hospital-acquired infections, and
preventable trauma. This analysis explores an adverse medication event at Christus Health
System’s Medical-Surgical Unit, a Magnet-designated facility in Texas. The primary focus is on
medication safety, particularly adherence to the six rights of medication administration,
infection prevention, and fostering a culture of safety and accountability. This case study aims to
identify contributing factors, evaluate systemic failures, and propose evidence-based strategies
for improvement.
Medication Error Case Analysis
The case involves a 37-year-old male patient admitted postoperatively from the orthopedic
ward. The patient received enteral nutrition via a nasogastric tube and was prescribed both
short- and long-acting insulin. On the morning of the incident, the nurse on duty noted a blood
glucose level of 162 mg/dL and administered four units of short-acting insulin without
confirming the patient’s meal status. The patient subsequently developed severe hypoglycemia
and became unresponsive.
This event highlights multiple medication administration errors, including the failure to verify
patient readiness for insulin, confirm meal availability, and adhere to the six rights of medication
safety. Furthermore, discontinued medications were inadvertently administered, compounding
the adverse event. This assessment examines contributing factors, system-level failures, and
stakeholder impacts to guide future improvement initiatives.
Analysis of Missed Steps Related to the Adverse Event
The nurse in question was responsible for eight patients during a high-turnover shift, leading to
significant workload pressure. Time constraints hindered her ability to review orders, confirm
medication appropriateness, and verify that the insulin order was contingent upon food intake.
The second nurse, serving as a witness, was similarly overextended and unable to cross-check
the order.

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3. According to Silva and Krishnamurthy (2020), preventable medical errors impact over seven
million patients annually, costing the U.S. healthcare system approximately $21 billion. The lack
of situational awareness and communication among the care team led to a sequence of
oversights, ultimately resulting in patient harm. Proper communication, order verification, and
cross-checking could have prevented this near-fatal event.
Systemic Failures in Patient Safety
This incident reveals broader systemic failures, including inadequate communication between
units, poor staffing ratios, and insufficient nurse training. As Phillips and Malliaris (2021)
emphasize, the demanding nature of nursing practice makes healthcare professionals
vulnerable to errors, especially under high workload conditions. The nurse’s inability to verify
the patient’s feeding status and medication discontinuation reflects systemic issues rather than
isolated negligence.
Root cause analysis indicates that insufficient interdepartmental coordination, staff fatigue, and
lack of ongoing education on insulin administration were contributing factors. Addressing these
issues requires structural interventions that enhance communication, optimize staffing, and
reinforce medication safety education.
Implications of the Adverse Event on Stakeholders
Adverse medication events negatively affect all stakeholders—patients, providers, and the
organization. Patients lose trust in healthcare systems, potentially avoiding future care, while
clinicians experience guilt, anxiety, and diminished confidence. Hanson and Haddad (2022)
report that healthcare professionals involved in errors often feel traumatized, stressed, and self-
doubtful following adverse events. Furthermore, institutional reputations suffer, potentially
leading to financial losses through denied insurance claims or patient attrition.
For Christus Health System (CHS), restoring stakeholder trust requires implementing transparent
reporting mechanisms, continuous staff education, and systemic process redesigns to ensure
sustained patient safety and quality of care.

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4. Evaluation of Quality Improvement Technologies
Quality Improvement (QI) initiatives drive organizational transformation and foster frontline
engagement. As Backhouse and Ogunlayi (2020) note, QI enables both micro-level (patient-
specific) and macro-level (systemic) enhancements. A valuable technological intervention for
CHS would be the implementation of a real-time interactive patient dashboard—a digital tool
designed to track patient data, clinical metrics, and medication workflows (Alhmoud et al.,
2022).
This dashboard could enhance medication safety by displaying alerts for meal-dependent insulin
administration, flagging discontinued medications, and tracking compliance with the six rights
of medication administration.
Implementing an Interactive Patient Dashboard
The proposed interactive patient dashboard would serve as a centralized platform integrating
nursing assessments, medical orders, and interdisciplinary communication. It would provide
visual alerts, electronic reminders, and patient-specific indicators such as blood glucose trends
and nutritional status. By ensuring accessibility across devices, nurses can make timely, data-
driven decisions and prevent future medication errors.
Pilot testing should be conducted to evaluate functionality, user satisfaction, and integration
with CHS’s existing electronic health record (EHR) system. This stepwise deployment aligns with
best practices in QI, emphasizing iterative improvement, stakeholder feedback, and measurable
outcomes (Helminski et al., 2022).
Relevant Metrics of Quality Improvement for CHS
Key Performance Indicators (KPIs) serve as quantifiable benchmarks for assessing clinical
performance. Phillips and Malliaris (2021) describe KPIs as essential tools for tracking healthcare
quality and safety outcomes. For CHS, relevant KPIs may include:

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5. • Medication error rates
• Insulin administration compliance
• Adverse event frequency
• Staff adherence to clinical protocols
• Patient satisfaction and safety incident reports
By monitoring these metrics via the dashboard, CHS can identify trends, implement targeted
interventions, and evaluate improvement over time. Data integration with national benchmarks,
such as the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators, further
ensures transparency and accountability (Farquhar, 2022).
Outline for a Quality Improvement Initiative for Christus Health System
Integrating PDSA and Six Sigma Frameworks
To enhance patient safety and reduce adverse events, CHS can integrate the Plan-Do-Study-Act
(PDSA) model with Six Sigma methodologies. PDSA emphasizes iterative testing and gradual
process improvement, while Six Sigma employs data-driven analysis to eliminate variability and
defects (Helminski et al., 2022). Together, these models create a robust framework for quality
enhancement.
PDSA Cycle:
1. Plan: Identify the problem—insulin administration errors—and develop targeted
interventions.
2. Do: Pilot the dashboard and training modules in one medical-surgical unit.
3. Study: Analyze pre- and post-implementation data to assess effectiveness.
4. Act: Scale successful strategies hospital-wide and institutionalize best practices.
Using both approaches enables CHS to implement evidence-based interventions that reduce
risk, improve communication, and strengthen the culture of safety (Coury, 2020).

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6. Conclusion
This analysis underscores the importance of robust systems, interdisciplinary communication,
and continuous quality improvement in preventing medication errors. Through implementing
technology-driven solutions such as an interactive dashboard and integrating proven QI models
like PDSA and Six Sigma, Christus Health System can significantly enhance patient safety
outcomes. Sustained leadership support, staff engagement, and data-driven monitoring will
ensure the success of these initiatives and restore trust among patients and stakeholders.
By fostering a culture of learning, accountability, and innovation, CHS can position itself as a
leader in delivering safe, high-quality, and patient-centered care.
References
Alhmoud, A., et al. (2022). Digital dashboards in healthcare: Improving patient safety through
data integration. BMJ Open Quality, 11(3), e002033. https://doi.org/10.1136/bmjoq-2022-
002033
Backhouse, T., & Ogunlayi, F. (2020). Quality improvement: Theory and practice in healthcare
transformation. BMJ, 368, m865. https://doi.org/10.1136/bmj.m865
Coury, J. R. (2020). Applying PDSA cycles in nursing practice for patient safety enhancement.
BMC Health Services Research, 20(1), 1–12. https://doi.org/10.1186/s12913-017-2364-3
Farquhar, M. (2022). Quality indicators and patient safety: AHRQ framework for healthcare
improvement. NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK560654/
Hanson, C. M., & Haddad, L. M. (2022). Impact of medical errors on healthcare professionals
and systems. StatPearls Publishing.
Phillips, J., & Malliaris, A. (2021). Human factors and systemic safety in nursing practice. Journal
of Nursing Care Quality, 36(4), 312–319.
Silva, R., & Krishnamurthy, A. (2020). Preventable medical errors and cost burden in U.S.
healthcare. Health Services Management Review, 45(3), 142–150.
Skelly, M., et al. (2023). Preventable adverse events in clinical practice: Trends and mitigation
strategies. Patient Safety Journal, 18(2), 89–104.
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