Risk Management

Risk management paper

Risk management is defined as a program directed toward identifying of, evaluating of, and taking corrective action against potential risks that could lead to injury of patients, staff, or visitors. It is a planned program of loss prevention and liability control, and its main purpose is to identify, analyze, and evaluate risks and then to develop a plan for reducing the frequency and severity of accidents and injuries (Decker and Sullivan, 2001). Risk management is a continuous daily program of detection, education, and intervention. This paper will describe the risk management issues at Great River Medical Center as they pertain to medication errors, and will describe the methods that are currently taking place to address this issue.

Identifying Potential Risk

Identifying potential risks for accident, injury, or financial loss requires formal and informal communication that involves all organizational departments in the facility. The risk management department at Great River Medical Center conducted on study on medication errors in the facility during preparation for a JACHO inspection. During this study, they discovered that medication errors had increased steadily over a 2 year period, and that many of them were because of illegibility reasons. The two most common legibility reasons included reading the initial order and reading the medication on the hand written medication sheet.

According to Michael R. Cohen, MS, FASHP, from the Institute for Safe Medication Practices, poor handwriting is the leading cause of medication errors. Poor handwriting can blur the distinction between two medications that have similar names. And, many drug names sound similar, especially when spoken over the telephone, enunciated poorly, or mispronounced.

At Great River Medical Center, this was also found to be one of the leading causes of medication errors. The inability of the nurse to read the written order and the inability to read the written medication sheet accounted for 20 % of the medication errors at GRMC. Other reasons for medication errors at GRMC include the following:

 Incomplete patient information (not knowing about patients' allergies other medicines they are taking, previous diagnoses, and lab results, for example);

 Unavailable drug information (such as lack of up-to-date warnings);

 Miscommunication of drug orders, which can involve confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations;

 Lack of appropriate labeling as a drug is prepared and repackaged into smaller units; and

 Environmental factors, such as lighting, heat, noise, and interruptions, which can distract health professionals from their medical tasks.

 Delay or omission of scheduled medications (this accounted for 30% of medication errors at GRMC).

Methods for Resolution

Hospitals have begun making a number of improvements to reduce medication errors, and Great River has begun to implement many of these measures. The following are measures that are being utilized in many facilities:

Ð'* New computerized order-entry systems in hospital pharmacies minimize mistakes that come from reading physician handwriting, she says. The system sends an "alert" message, asks questions, prompts the pharmacist to review and question the prescription's accuracy.

Ð'* Each patient now wears ID badges with bar codes -- which can be matched with their medications, to ensure accuracy.

Ð'* "Hospitalists" are medical doctors that are now based in many critical care hospital units; they track and manage patient care in that unit. "We're seeing it more and more -- a physician on site to manage care of patients rather than nurses," says O'Keefe. "It provides better continuity of care."

Ð'* Healthcare facilities are focusing less on blame -- and more on safety. If a mistake or near-mistake happens, the person involved is encouraged to step forward, describe it, and instead of blaming them, the organization looks into how the mistake happened, what can be done to prevent it from happening again. It helps prompt more people to come forward (Web MD, 2004).

Computerized order entry and computerized dispensing machines have become more the norm in hospitals to day as a way to reduce medication errors. Great River Medical Center utilizes the Omni cell dispensing machine and Omni cell Link Rx for computerized order entry. This has helped to reduce medication errors due to poor handwriting and misinteruptation drastically. However, new studies conducted over the past five years by U.S. Pharmacopoeia show that computerized order entry can cause many medication errors. Errors occurred in all phases of using the systems, including entering incorrect or incomplete information such as patient names, drug doses or lab test results. The mistakes that occur as a result of these systems tend, however, to be about half as likely to harm patients, the group found.

The use of bar codes that can be scanned on the patient's identification bracelet is currently not utilized at GRMC, but the facility is planning to implement a system within a two year period. This system matches the patient's name to their medications and helps to insure that the right dose is given at the right time. This system also alert the nurse of potential allergies that the patient has so that a medication that the patient is allergic to can not be dispensed.

The use of Hospitalist's are currently being utilized at GRMC, and their main focus currently