Risk Management Helps to Prevent Errors

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.