Impact of Near-Miss Events on Patient Safety and Quality Improvement Essay

Adverse events are “all adverse medical events that occur after a patient receives treatment and do not necessarily have a causal relationship with the treatment” (Liu et al., 2020). Patient safety and quality of care are severely impacted when an adverse event occurs. In the United States, it is reported that medical errors or adverse events are the third leading cause of death, with 1.1% of hospital admissions leading to medical errors (Schwendimann et al., 2018). Despite recent technological advances, increases in medical oversight, ongoing patient care education, nurse and hospital staff training, hospital and patient care regulations, legislations, medical errors, and adverse events still need to be addressed.

This paper will define adverse events or near miss events, analyze a situation in which a near miss event occurred, analyze the implications of a near miss for stakeholders, analyze the sequence of events using a root cause analysis, evaluate and identify quality improvement actions to increase patient safety and outline a quality improvement initiative to prevent future adverse or near miss events.

An Adverse Event or a Near Miss From Your Professional Nursing Experience

The adverse event that will be examined in this paper involves an 82-year-old male patient presenting for a lung biopsy at St. Anthony Medical Center. The issue lay within the recovery period for the patient when he developed a pneumothorax that required a chest tube placement. This chest tube was somehow placed into the incorrect lung, requiring a second chest tube to be placed into the correct lung. Before the procedure, the patient was scanned, and a marking was placed in the correct area for the biopsy needle to enter. The patient was prepped and educated on the procedure and what to expect during and afterward. After the biopsy, the patient complained of some pain and seemed to be unable to catch his breath, although this was confusing due to the patient’s aphasia, which worsens with stress. The patient was flipped onto his belly to be made comfortable, obscuring the site marking, and the team rushed to place a chest tube to relieve the patient of his discomfort.

For the record, it is noted that “perioperative nurses are responsible for providing safe patient care, including efforts to help prevent sentinel events, such as wrong site surgeries” (Mellinger, n.d.). Once the team got the necessary placement confirmation imaging following the chest tube placement, the doctor noticed that the pneumothorax was still present, and it was then discovered that the chest tube was placed into the incorrect lung. Through discussion with the team, it was discovered that due to the urgency the doctor placed on getting the chest tube placed to relieve the pneumothorax, there was never confirmation on the correct placement of the chest tube or the proper positioning of the patient to ensure correct placement was completed.

Stakeholder Implications of Adverse Events or Near Misses

Adverse events or near-miss events not only affect the patients but can also affect any stakeholders involved in the patient’s care. Stakeholders can include family members, hospital staff, the entire healthcare organization, and the patients themselves. While stakeholders can include all of the aforementioned members, patients are the biggest stakeholders at risk and affected by an adverse or near-miss event in healthcare. These errors occur directly to the patient, resulting in permanent injury or even death in serious cases, causing professional consequences for the healthcare workers involved. Healthcare organizations may incur organizational predicaments from a near miss or adverse event, which could lead to long-term difficulties with their patient and professional reputations, resulting in economic and financial hardships (Khakurel et al., 2020).

Root Cause Analysis: Identifying Events, Missed Steps, and Protocol Deviations

Nurses and other healthcare workers are the ones who are responsible for creating and maintaining a safe and practical environment for their patients, and ultimately, they must ensure that they uphold this throughout their practice. Once an adverse event is discovered, the nurse who discovered the error must report the error to the proper higher-ups. If an error is reported promptly, it may give the physicians time to correct the actions and determine a further plan of action to continue benefitting the patient’s care and health. Nurses must also abide by a “code of ethics,” so it is in their best practice to report the adverse event to management and, if indicated and present, an incident reporting system within the hospital (Claffey, 2018).

The patient involved in this adverse event did ultimately suffer unnecessary implications. Due to the entire team not realizing until it was too late that they were placing a chest tube into the incorrect lung, the patient, in turn, had to undergo another chest tube placement into his other lung to repair the pneumothorax that was a direct result of the lung biopsy he went in for. Implications of this sort could have been avoided had the team used the social worker’s assistance for the case, who had reached out before the surgery was completed.

Quality Improvement Actions and Technologies to Enhance Patient Safety

Several quality improvement (QI) actions and technologies can be employed to avoid such negative events or near misses in the future. First and foremost, standardizing the procedure for inserting chest tubes and requiring confirmation of proper insertion can improve patient safety (Bertoglio et al., 2019). When the patient was turned onto their stomach for comfort, the site marking was obscured, contributing to the mistake. As a result, it was challenging for the medical staff to ensure precise chest tube placement because the marking that designated the proper spot for the biopsy needle entry was no longer visible.

Additionally, the healthcare team members’ ineffective coordination and communication played a role in the incident. The omission of the social worker’s participation, who had contacted the patient before the procedure, could have helped to avert the error and provided useful suggestions and assistance (Junior et al., 2019). Therefore, one of the QI actions should be the creation of a protocol with clear instructions for patient positioning, site marking, and verification processes.

Other than the protocol, technological solutions can be used to increase patient safety. For instance, using image-guided techniques like fluoroscopy or ultrasonography can offer real-time visibility and guidance during the insertion of a chest tube, assuring precise location. These tools can help medical professionals confirm accurate placement and lower the chance of mistakes (Junior et al., 2019). There was a redundant injury for the patient, which required a second treatment to fix the mistake. Thus, to prevent physical and psychological suffering, extended hospital stays, and higher healthcare expenditures, there is a need for a technological intervention such as a proposed image-guided technique.

Benchmarking Solutions from Other Institutions for Prevention

Furthermore, it can be helpful to consider how other institutions have integrated solutions to stop such events. For instance, several hospitals have put surgical safety checklists in place, including precise actions to stop treatments from being performed in the wrong spot. The WHO recommended this in their publication about safe surgeries (WHO, 2023). These checklists act as cognitive assistance and ensure crucial procedures are not skipped, such as confirming the precise site and patient placement. This procedure will be beneficial not only for the patient, who experiences the primary harm but also for other stakeholders, including the hospital institution. If the case escalates to legal charges, the healthcare organization can suffer from a loss of patient trust and a damaged reputation, which will lead to financial repercussions in the long run.

Key Metrics Highlighting the Need for Improvement

Other pertinent metrics can also give important insights into the efficacy of adopted measures. For instance, monitoring the quantity of confirmed accurate chest tube placements might show whether the established methodology and verification procedures are continually being adhered to (Korymasov et al., 2021). The rate of pneumothorax complications can be assessed to determine whether there has been a decrease in these complications as a result of the QI activities. Additionally, getting feedback on patients’ and healthcare professionals’ experiences and perceptions of patient safety can provide qualitative data to supplement the quantitative metrics and provide a thorough understanding of how the QI initiatives have affected patient safety.

Conclusion

In conclusion, the near-miss adverse event study involving the installation of a chest tube during a lung biopsy surgery emphasizes the significance of patient safety and the demand for quality improvement in healthcare facilities. Patients are not the only ones affected by adverse events and near-misses; other stakeholders, such as healthcare organizations and providers, also face serious consequences. A root cause investigation revealed that the near-miss occurrence was caused by missed steps, procedure violations, and communication breakdowns. Standardized protocols, image-guided processes, and event reporting systems are just a few of the technologies and quality improvement initiatives that can be used to reduce the risk of incidents of this nature. Healthcare companies may proactively resolve risks, guarantee patient safety, and deliver high-quality care by learning from prior near-misses and unfavorable incidents.

References

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