Risk Management Issues For Medication Erros

Risk Management Paper

Worldwide, health care organizations struggle with adverse drug events caused by countless medication errors. Medication errors have been an ongoing problem for many years. These errors not only create potential patient safety concerns, but also increase health care costs. Medication errors happen most frequently around the busy times of administration. According to Agency for Healthcare Research and Quality (n.d.), “Adverse drug events (ADEs) result in more than 770,000 injuries and deaths each year and cost up to $5.6 million per hospital, depending on size. Many ADE injuries and resulting hospital costs can be reduced if hospitals make changes to their systems for preventing and detecting ADEs” (para. 1). In this paper, it will talk about a risk management issue on a near miss and preventable medication error, and discuss the steps to address and solve the issue. It will also talk about three sources that identify valid methods adopted by other facility, and how these processes are valuable methods to Morristown Medical Center (MMC).

Risk Management Issue

Back when electronic MAR was not introduced to the organization of MMC, MARs were transcribed by hand by the nurses on a paper MAR. Orders were faxed to pharmacy in which the pharmacists entered them in their computer systems. Medications were sent up from pharmacy to the units while the nurses administered them to the patients in accordance to the MAR they had written out. One day a nurse who was orienting a new graduate nurse for almost 4 weeks had noted a medication error. She noticed that a medication Levaquin written by the doctor from two days prior was incorrectly written wrong on the paper MAR. The doctor wrote Levaquin 500 mg IV “QOD”. The one...

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...at MMC does to increase staff knowledge in reduction of medication errors is to use of incident report as tool for improvement and decrease the staff’s fear about it. Base on literature reviews, medication errors are immense problem in healthcare. MMC established incident peer review committee and process as part of an intervention to improve medication safety. For example, the process entails meeting with the core committee and reviewing incident cases of medication errors. They obtain agreement on conclusions of incident. A member from the IBPR committee then meets with the RN’s manager with a proposed action plan and follows up in three months for the implementation of action plan and completion time. The main purpose of this is to provide a non-punitive, learning environment to address incidents and provide an objective team approach involving registered nurses