Portfolio Project Case Study

Portfolio Project Case Study
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Introduction
There are several factors that contribute to safety and medication errors within the health care system. Some of the factors that cause these errors are directly attributed to the organizations that are providing healthcare while others are attributed to the medication-use system. In most of the cases multiple factors are involved in these errors (Aspden, Wolcott, Bootman, & Cronenwett, 2007). The case study is an illustration of the complexities within the health care system and the process for medication usage and the inter-related nature of factors that are involved in the provision of quality and safe care (Aspden et al., 2007).
The physicians, nurses, and pharmacists of the hospital were not familiar with the treatment of congenital syphilis and had limited knowledge regarding the use of congenital syphilis drugs. The pharmacist that was filling the prescription made consultations with the infant progress notes. In the notes the nurse practitioner documented a recommendation for treatment for the health department (Aspden, Wolcott, Bootman, & Cronenwett, 2007). In addition, the pharmacist consulted a drug reference book and used it to determine the normal dose for penicillin G benzathine for infants. The pharmacist, however, erroneously read in both of the sources as 500,000 units/kilogram (kg), an adult dose instead of 50,000 units/kg (Aspden et al., 2007).
As a result, she misread the order as 1,500,000 units/kg since the "U" representing units was written as a zero hence added a zero to the dose. She prepared the dose as read and this was a 10 fold overdose. Due to the absence of constant pharmacy procedure for double checking this error went undetected (Aspden, Wolcott, Bootman, & Cronenwett, 2007). The label on the bag used for dispensing the drug indicated 2.5 milliliters (ml) of the prepared medication was to be administered intramuscularly (IM). This was to equal the 1,500,000 units/kg dose (Aspden et al., 2007). This dose led to the death of the patient.
The Role of a Risk Manager in Addressing the Case
Reducing risks and ensuring safety demand greater attention to the systems that are responsible for assisting in the prevention and mitigation of errors. Today, the popular quote "crossing the Chasm" provides suggestions that risk management and the improvement of quality efforts within healthcare organizations are pushing for patient safety and quality. In addition, establishing the means of effectively and efficiently working in an interdisciplinary manner to ensure organizations deliver safe and high-quality care (ECRI Institute, 2099).
Initiatives have been put in place that have forged alliances, and this began with the report by IOM in 1999 entitled "To Err Is Human: Building a Safer Health System." This emphasized the importance of health care organization to monitor from events arising from patient safety (ECRI Institute, 2099). According to ASHRM, the role of a risk manager has changed today. This survey indicated that the functions of a risk manager include risk identification and evaluation, prevention of loss, ensuring the safety of the patients, and education (ECRI Institute, 2099). Effective risk management comprises of every level of the health care service or organization hence the need for employees to comprehend the need for risk management strategies (ECRI Institute, 2099).
Clinical risk management is concerned with improving the quality and safety of care through the identification of circumstances and opportunities that put patients in harm’s way and then act to control the risks. Risk management involves four steps. These are risk identification, assessment of the severity of risk, reduce/eliminate the risk, and assessing the costs saved or spent in reducing the risk or where the risk occurs respectively.
The medication error resulted into the death of a newborn baby, and this resulted from the lack of proper procedures and guidelines including knowledge to handle the situation. Therefore, for risk management, the risk manager should first identify and evaluate the source of the risk that from this case study arises from a myriad of factors. These are, for example, the lack of knowledge on drug treatment of congenital syphilis by the health care providers and the erroneous reading of the prescription order by the pharmacist. In addition, there is a lack of institutional checks and procedures for drug administration and treatment just to mention a few. Following risk identification and evaluation, the risk manager should come up with means of ensuring that no similar losses are experienced in the future, and this is achievable by setting up treatment guidelines and protocols for such patients. Moreover, the risk manager will be key in ensuring that the health care providing team has received the education and training required in the field to ensure that there are no future losses.
Moreover, per the IOM, all the processes that are associated with administration of medications require evaluation for safety and given priority for improvement of the quality as need arises (Benet, 2008). Therefore, the risk manager has the role of conducting evaluations of the medication administration processes to ensure they provide the best safety and health outcomes. This according to the IOM can be attained using three strategies. These are designing systems that prevent such errors, designing procedures to make the errors visible when they occur, and designing procedures that eliminate harm to the patient from the errors detected (Benet, 2008). These are the roles of the risk manager in the current situation.
The Requirements of the Joint Commission of Reporting Sentinel Events for a Hospital
The Joint Commission in support of its mission of guaranteeing that safety and quality care is provided to the public is continuously improving. It reviews hospital activities in its accreditation process in response to sentinel events (Jcr, 2009). This process includes all accreditation surveys and where appropriate cause-surveys and random validation surveys that are specific to Evidence of Standard Compliance (ESC). Sentinel events are the unexpected occurrences that involve the death, serious physical injury, serious psychological injury, or any risks involved thereof (Jcr, 2009). Serious injury here comprises of loss of limb or function and the term "or the risk thereof" comprises of any process variations whose re-occurrence increased susceptibility to serious deleterious outcomes. These events are referred to as sentinel events as they are an indicator for the need for investigation and timely response. Two term "sentinel event" and "error" are not synonymous as sentinel events occur erroneously, and not all erroneous occurrences are sentinel events (Jcr, 2009).
The Joint Commission may be become aware through voluntary self-reporting or other forms of reporting of a sentinel event meeting the policy’s criteria. If the event is within an accredited hospital the hospital is required to first prepare an analysis that is thorough and credible of the root cause and a plan for action within 45 days of the occurrence of the event or becoming aware of the event (Jcr, 2009). Second, submitting to the Joint Commission the analysis of the root cause and the action plan or as otherwise provided by the Joint Commission evaluation of the response to the sentinel event under a protocol that is approved within 45 days of the occurrence of the event. If the hospital does not submit the root cause analysis within an additional 45 days after its due date. Its accreditation status may be affected (Jcr, 2009).
Steps a Risk Manager Should Take to Address the Events in the Case Study
The management of risks includes as mentioned earlier conducting risk assessments and establishing risk mitigation strategies for the risks. Risk assessment here includes the identificat...