Ways that the risk manager could prevent this type of event happening in the future would be to establish and maintain a functional pediatric formulary system with policies for drug evaluation, selection and therapeutic use. To prevent timing errors in medication administration, standardize how days are counted in all protocols by deciding upon a protocol start date. Limit the number of concentrations and dose strengths of high alert medications to the minimum needed to provide safe care. Assign a practitioner trained in pediatrics to any committee that is responsible for the oversight of medication management. Develop preprinted medication order forms and clinical pathways or protocols to reflect a standardized approach to care. Include reminders and information about monitoring parameter. On inpatient medication orders and outpatient prescriptions, require prescribers to include the calculated dose and the dosing determination, such as the dose per weight (e.g., milligrams per kilogram) or body surface area, to facilitate an independent double-check of the calculation by a pharmacist, nurse or both. Finally, have a pharmacist with pediatric expertise available or on-call at all times (Preventing pediatric medication errors, n.d.).
To control the event from happening again, enforcing all of the suggestions above would significantly lower the chances of the event happening again. Above all education was severely needed on the unit. Setting up a education seminar for two weeks at staggered times, allowing all staff involved to educate themselves on the pitfalls that occurred. A risk manager would also need to routinely set up surprise inspections on the unit. Following a checklist of what should happen...
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...s are believed to be the most common type of medical error and are a significant cause of preventable adverse events (Preventing pediatric medication errors, n.d.). Risk managers play a tremendous role in preventing and controlling the risks that arise in healthcare. Performing routine mock safety inspections in all units of the hospital can bring life to risks that occur in the ever-changing atmosphere of hospitals. Sentinel events may seem like a detrimental setback to a healthcare organization. However, by re-evaluating current policies and procedures on a regular basis can uncovered unsafe practices that are in place. Everyone that works in healthcare have the same goal, to keep patients as safe as possible and provide the best care. Risk managers hold those same set of standards even if their job description is different than a clinical professional.
It is imperative that Health Care Professionals learn to manage risk. There are many factors to think about including environment, assessment, identification and prioritising when managing risk. Being able to strategically implement preventative measures will help in managing risk. Risk management works hand in hand with all enablers set out by chapelhow.
According to Poorolajal, medical errors occur when health care providers choose inappropriate methods of care or improperly execute an appropriate method of care (Poorolajal, et al. para 5 -10), which could potentially lead to loss of life and severe or permanent trauma to the victim. Valiani et al. argues, “Committing an error is part of the human nature” (540). Valiani et al. insist that no health care practitioner is immune to committing an error event if they demonstrate mastery of their skills (540). However, error in health care systems is dependent on many causes and factors. Management of such factors is essential to reducing the occurrence of errors in a health care system. Therefore, what strategies can medical practitioners implement to reduce medical errors? Medical practitioners can implement strategies such as communication, verification, and eliminating extended work shifts. These strategies are most effective because they help medical providers fulfill their full potential in doing their job in the most effective
...occurrences including sentinel events, near misses and serious occurrences; Detail of program activities that the high-risk process components; Results of the high-risk or error-prone processes selected for ongoing measurement and analysis; results of input from patients and families participation in improving patient safety is obtained; report medical/health care errors description of education and training programs that are maintaining and improving employee proficiency and supporting approach to patient care (Ihi.org,2011).
Baccalaureate nurses are responsible for providing and ensure our patients safety. The knowledge from others mistakes can help informs nurses of extra precautions that we can take to ensure our patient’s safety. Risk Analysis and Implication for practice course helped me understand the steps I as a nurse can take as well as the facilities I work for to help reduce the number of medication errors that occur. Interviewing the pharmacist help me get a better insight to what facilities already have in place to help prevent medication errors. However like most things you have to have educated and compassionate caring staff to enforce and follow the guidelines set in place.
The purpose of this paper is to show most of medication errors occur on the night shifts and the weekend shifts in pediatric care, Bar Code Medication Administration System’s success on extremely low medication errors in pediatric care, and tenfold medication errors in pediatric care.
Nurses are expected to provide a competent level of care that is indicative of their education, experience, skill, and ability to act on agency policies or procedures. In a study of 1,116 hospitals Bond, Raehl, and Franke (2001) found, “Medication errors occurred in 5.07% of the patients admitted each year to these hospitals. Each hospital experienced a medication error every 22.7 hours (every 19.73 admissions). Medication errors that adversely affected patient care outcomes occurred in 0.25% of all patients admitted to these hospitals/year”(p. 4). This means at least one medication error occurs every 24 hours in those facilities studied, and these are preventable errors. The main responsibilities of nurses when administering medications are to prevent or catch error, and report such error. Even if the physician or prescribing health care professional has made a mistake in the order, it is the nurse’s job to question the
The authors of Computerized Physician Order Entry and Medication Errors in a Pediatric Critical Care Unit explored the effectiveness of computerized physician order entry (CPOE) systems on medication errors. The study’s stated purpose was “to see the impact of CPOE on the frequency of medication errors at the degree of physician ordering in a pediatric critical care unit (PCCU)” (Potts, A.L., Barr, F. E., Gregory, D. F., Wright, L., & Patel, N. R., 2004). The work was set in the PCCU of an academic foundation and included medication errors from the two month period before the implementation of CPOE – October 4, 2001 to December 4 2001 – and a two month period after CPOE – January 4, 2002 to March 4, 2002 – with a one month period in between when no information was garnered in order to acclimate hospital staff (Potts et al., 2004). Each error was categorized into one of three groups: potential adverse drug effects (ADEs), medication ordering errors (MPEs), and rule violations (RVs). The results
Medication errors in children alone are alarming, but throw an ambulatory care setting into the mix and it spells disaster. When it comes to children and medication in the ambulatory care setting, the dosage range is drastically out of range compared to those that are treated in the hospital setting (Hoyle, J., Davis, A., Putman, K., Trytko, J., Fales, W. , 2011). Children are at a greater risk for dosage errors because each medication has to be calculated individually, and this can lead to more human error. The errors that are occurring are due to lack of training, dosage calculation errors, and lack of safety systems. Medication errors in children who are receiving ambulatory care can avoided by ensuring correct dosage calculation, more in-depth training of personal and safety systems in place.
A newly employed critical care nurse was just about to finish a 12 hour night shift when she realized she had one more patient to administer medication to. It was the busiest Friday night shift she has ever worked due to poor nurse-patient ratio, and the workload felt impossible. She gave her last patient the properly prescribed medication, but failed to notice that the physician hastily wrote an updated dosage for a high risk medication, Digoxin. The patient’s heart rate began to slow down and life-saving procedures had to be activated. Medication errors are “any preventable event that may cause, or lead, to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer
The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help to improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are unfortunately preventable. But, it is clear that errors caused in healthcare thousands of deaths in the United States.
The most commonly identified causes of these sentinel events include human factors, flawed leadership, and poor communication (“Sentinel event statistics released for 2014,” 2015). The concept of human factors can be applied to the individual, the healthcare team, and how a person performs and works within their environment (Doerhoff & Garrison, 2015). Individual human factors that have a negative impact on the delivery of patient care include cognition, fatigue, and physical ability (Doerhoff & Garrison, 2015). TJC has found that failed leadership within the healthcare setting fails to create a safe culture that allows sentinel events to occur (Ulrich, 2017). Hospital leaders can construct a culture of safety by focusing on accountability, recognizing unsafe conditions, trust, strengthening systems, and continually evaluating and assessing how they can improve patient and employee safety (Ulrich, 2017). Poorly communicating dietary restrictions, administration, and patient information amongst members of the healthcare team has significantly contributed to medical errors (Ulrich, 2017). From 1995 to 2015, TJC recognized ineffective communication as the leading root cause of sentinel events (Burgener,
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
Risk Management As a financial institution in current volatile financial market, we engage in both commercial and investment banking activities and are registered to do business in Germany and the US. Our business are providing multi-product financial service to clients, such as understanding service and stock research, as well as the traditional funding and investment activities. Our company tries to provide high service quality, innovation. The most important is we remain the maximization of shareholders profit as the Board's aim forever. In order to perform the business efficiency and effective, normally the board is responsible for approving group's strategy, principle market and acceptable risk.
A candidly of risk occurs in every organisation. Governance principals and the occupational health and safety urge that the organisations take reasonable measures to hinder loss, charge or rage to the organisational and all stakeholders/management. Injury and accidents can even happen ultimately with stringent OHS and the fact that an accident when occurs, does not mean that someone is liable if all responsible steps for prevention or minimisation has been taken.
I was also responsible for monitoring medication orders and reviewing patient profiles to ensure that the proper drugs and dosages were prescribed and that the pharmacy technician had prepared them properly. In many instances there were mistakes made in the preparation phase and sometimes even before, with incorrect dosages or drugs being prescribed and prepared, which could result in serious adverse effects for the patient. A clinical pharmacist’s role, however, is to make sure that these mistakes never reach the