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 JACO 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, FASH P, 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: o 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. o Each patient now wears ID badges with bar codes -- which can be matched with their medications, to ensure accuracy.
o '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.' o 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 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 is on the ICU patients. The hospital currently employees two and is looking to expand that group in preparation for a new open heart wing at the facility. A study conducted at Brookhaven Memorial Hospital Medical Center in East Patchogue, New York, compared results between patients treated by voluntary attending physicians and those treated by the hospital ist / clinical pharmacist team.
The study showed that the hospital ist / clinical pharmacists group had a 23 percent shorter length of stay, a 21 percent lower cost of medications and 1. 5 fewer medications per patient than the comparable patient group treated by the voluntary attending model. The hospital ist-pharmacist group also required less nursing care, and had a reduced risk of adverse drug reactions and medication errors (Business Wire, 2004). The vast majority of near misses, errors and adverse events arise from system problems; many go unrecognized or unreported. Improving patient safety requires a shift in organizational culture from one of shame, blame and punishment, which impedes error detection, to an atmosphere in which people can openly discuss safety issues and system improvements without the fear of retaliation (Anonymous, 2004). At GRMC, a 24 hotline has been installed to report medication errors and near misses.
Performance improvement forms are also filled out by the person finding the problem, and a review is done to see what system actually failed. The nurse, physician or pharmacist is kept appraised of what is found, and if the incident is serious enough a root-cause analyses is done. If an incident causes death or serious harm, counseling is offered to the person or persons that were involved. Termination or suspension from a job is only done if neglect and malicious intent are determined to be the cause of the error.
GRMC also holds mandatory medication competencies for all nurses, physicians and other medical providers is done on a yearly basis and includes all age groups. The organization also gives medication tests to all new hire nurses and they must pass by 80% to give medications on the nursing floor. The hospital also has pharmacists assigned to each floor, and they are available to consult on questions and concerns with medications. After hours, a pharmacist is available in the hospital to consult with on medication concerns. Since the implementation of the above programs and procedures, GRMC is seeing a drastic reduction in medication errors, and is seeing a reduction is near misses. The organization continues to monitor these rates, and it is the intended desire to see the reduction continue with each new implementation process.
With the use of the Omni Cell dispensers, computerized order entry, and the electronic medical record, the hospital has seen a reduction of errors and near misses at approximately 75%. Along with this great statistic, also comes peace of mind to an already stressed out and over worked staff, that wants to provide the best care possible for the patients. References: Anonymous, (2004). Nursing BC. Vol.
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