NSG/451 Week 2: Leadership in Quality and Risk Management, sample paper

Two Near Misses With Heparin Infusions on a Telemetry Unit: The Nurse Leader's Role in Quality and Risk Management

[Student Name]

University of Phoenix

NSG/451: Professional Nursing Leadership Perspectives

Week 2 Assignment

[Instructor Name]

[Date]

The unit, events and staff are a composite written for a model paper. No real patient is described.

In one month, a 30-bed telemetry unit reported two near misses with weight-based heparin infusions. In the first, a nurse programmed an infusion using the rate for a different concentration than the bag hanging on the pole; a second nurse caught it at the independent double check. In the second, a nurse bypassed the pump's drug library to start an infusion quickly during an admission, and the rate was entered as milliliters per hour when the order was written in units per hour. The pharmacist reviewing the anticoagulation panel noticed the discrepancy about 40 minutes later, before any bleeding occurred. Neither patient was harmed. Near misses are the cheapest lessons a unit will ever get, and a leader who treats them as luck rather than information is waiting for the version that reaches a patient. This paper examines the nurse leader's role in responding to these two events, from analysis through corrective action and follow-up measurement.

Quality and Risk: Two Roles for One Leader

Risk management and quality improvement overlap but ask different questions. Risk management asks what could harm a patient, staff member or the organization, and how to prevent or contain that harm. Quality improvement asks how well care achieves the outcomes it is meant to achieve, and how to make it better. Marquis and Huston (2021) place both inside the nurse manager's controlling function, because both depend on measuring what actually happens against a standard.

In these events the risk question is immediate: heparin is a high-alert medication, and a tenfold rate error can cause a major bleed. The quality question is slower: why does a unit with smart pumps, a double-check policy and a pharmacist still produce programming errors? The charge nurse owns the immediate risk response on the shift, which includes stopping the infusion, notifying the provider, checking the patient and reporting the event. The nurse manager owns the quality response, which includes the analysis, the corrective plan and the measurement that follows. A leader who handles only the first role closes the incident; a leader who handles both closes the gap that produced it.

Analyzing the Events as a System

Most errors come from faulty systems and processes rather than careless individuals, and blaming individuals does little to make care safer (Institute of Medicine, 2000). Reason (2000) made the same point with his model of layered defenses: an error reaches a patient only when holes in several layers line up at once. Read that way, the two near misses share a pattern.

The first event passed through three layers. The unit stocked two heparin concentrations in the same automated dispensing cabinet drawer, the order set displayed the dose in units per kilogram but not the rate for the specific bag, and the nurse was covering five patients during a shift change. The double check held, which is why the event stayed a near miss. The second event passed through different holes. The drug library was bypassable with two taps, the admission arrived during a period when the unit had one nurse on break, and the pump's default infusion mode displayed milliliters per hour first. In both cases the individual made the final slip, but the system made the slip easy.

Ohashi et al. (2014) reviewed the evidence on smart pumps and found that they can reduce some programming errors but do not prevent errors on their own, in part because nurses bypass the drug library and because pumps cannot catch the wrong bag or the wrong patient. The second event fits that finding exactly: the safety feature existed, and the workflow gave the nurse a reason to go around it.

Corrective Actions, Ranked by Strength

The Institute for Safe Medication Practices (ISMP, 1999) ranks error-reduction strategies from most to least effective: forcing functions and constraints first, then automation, then standardization and simplification, then checklists and double checks, and finally rules, policies, education and information. The ranking matters because the most common response to a near miss, a staff education session and a reminder email, sits at the bottom of that list.

Using that hierarchy, the nurse manager proposed four actions to the unit practice council and pharmacy.

1. Constraint: remove the second heparin concentration from the unit's cabinet so that only one standard premixed bag is available for weight-based infusions. With one concentration, the first error becomes impossible on this unit.

2. Automation: ask pharmacy and biomedical engineering to set heparin as a hard limit in the drug library and to require the library for all heparin infusions, so that the bypass in the second event would no longer be available.

3. Standardization: revise the order set to display the calculated rate in units per hour and milliliters per hour for the standard bag, so the nurse compares like with like.

4. Double check with a script: keep the independent double check but give it a short script (patient, bag concentration, dose in units per hour, rate in milliliters per hour, pump screen) so that it tests the same items every time.

Education appears in the plan only as the way staff learn about these changes, not as the fix itself. The first two actions are the strongest because they change what the nurse is able to do, not only what the nurse is asked to remember.

Reporting Culture and Accountability

Neither event would have reached the manager without a report, and the second one was reported by pharmacy, not the unit. Reason (2000) argues that a safe organization depends on a reporting culture, which in turn depends on staff trusting that honest reports will be treated fairly. The manager's response to the two nurses therefore shapes whether the next near miss is reported at all. In this case the manager met with both nurses, reviewed the events without assigning blame for system factors, and made clear that the second nurse's choice to bypass the library was a behavior to change, not a firing offense. She then thanked the pharmacist and the double-checking nurse at the next staff huddle by describing what they caught, without naming the nurses involved in the events. Fairness to individuals and firmness about unsafe choices are both part of the leader's risk role.

Measuring Whether the Fix Held

A corrective plan without measurement is only a hope. The manager set three measures for the next six months: the percentage of heparin infusions started through the drug library (from pump data), the number of heparin-related events reported per month, and the percentage of double checks that followed the script in monthly observation audits. She also agreed with pharmacy to track anti-factor Xa or aPTT results outside the target range within the first 24 hours of infusion, which is an outcome measure rather than a process measure. A drop in reports alone would not prove success, because it could mean less reporting rather than fewer errors, so the library compliance and audit data carry the evaluation.

Conclusion

Two near misses with heparin on one telemetry unit exposed a set of aligned weaknesses: two concentrations in one drawer, an order set that did not show the rate, and a pump library that was easy to bypass. The nurse leader's role in quality and risk management was to turn those events into information, choose corrective actions strong enough to change the system, protect the reporting culture that surfaced the events, and measure whether the change held. Handled that way, two harmless events do the work that a serious one otherwise would have done.

References

Institute for Safe Medication Practices. (1999, June 2). Medication error prevention "toolbox." ISMP Medication Safety Alert!, 4(11). https://www.ismp.org/resources/medication-error-prevention-toolbox

Institute of Medicine. (2000). To err is human: Building a safer health system. National Academies Press. https://doi.org/10.17226/9728

Marquis, B. L., & Huston, C. J. (2021). Leadership roles and management functions in nursing: Theory and application (10th ed.). Wolters Kluwer.

Ohashi, K., Dalleur, O., Dykes, P. C., & Bates, D. W. (2014). Benefits and risks of using smart pumps to reduce medication error rates: A systematic review. Drug Safety, 37(12), 1011-1020. https://doi.org/10.1007/s40264-014-0232-1

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768