Risk Management Helps to Prevent Errors Essay

Each year, roughly 1.5 million adverse drug events (ADEs) occur in acute and long-term care settings across America (Institute of Medicine [IOM], 2006). An ADE is succinctly defined as actual or potential patient harm resulting from a medication error. To expound further, while ADEs may result from oversights related to prescribing or dispensing, 26-32% of all erroneous drug interventions occur during the nursing administration and monitoring phases (Anderson & Townsend, 2010). These mollifiable mishaps not only create a formidable financial burden for health care systems, they also carry the potential of imposing irreversible physiological impairment to patients and their families. In an effort to ameliorate cost inflation, undue detriment, and the potential for litigation, a multifactorial approach must be taken to improve patient outcomes. Key components in allaying drug-related errors from a nursing perspective include: implementing safety and quality measures, understanding the roles and responsibilities of the nurse, embracing technological safeguards, incorporating interdisciplinary collaborative efforts, and continued emphasis upon quality control.

Medication errors are preventable and cause great harm to the patients and their families. Every year in Australian hospitals, medication errors occur as nurses do not follow the 9 rights of medication administration. The 9 rights are right patient, drug, route, time, documentation, response, action and form (Fossum et al., 2016). Medication errors can be caused by

Risk assessment is a powerful means by which individual children can be encouraged to manage their own medication. Through agreeing a number of risks of a child administering their own medication such as giving themselves an incorrect dose, procedures can be put into place

In this situation by reporting the event, the organization can do something to fix the problem, maybe change the way that their medications are packaged or have two nurses to verify that the correct medication is given. Organizations should focus more on finding solutions instead of looking for people to blame.

Backup copies of appropriate vital records must be maintained in a secure off-site storage location. The off-site storage location has been selected due to its location which will ensure it is unaffected by the disaster since distance and accessibility were considered in site selection.

It is the goal of all healthcare providers and organizations to provide quality care to all patients without error. The truth is, even healthcare providers make some mistakes. The question is, when an error occurs who is to be held responsible? Is it, the nurse who administered the wrong medication, due to being overworked and lack of staff to help? Or is it the Healthcare Organization (HCO), because they should have fixed the staffing issues. There are so many factors that contribute to an error. I believe each situation should be properly investigated, before placing blame where it should or should not be placed.

The system failures identified by Judy Smetzer in the case of the newborn Miguel revealed interesting views concerning patient safety. In the article,” Lessons from Colorado: Beyond Blaming Individuals”, the difficulties of healthcare system and medication use system led to a fatal error that killed a newborn. This case emphasized that medication errors were not caused by a failure of one single element, but the whole system. According to Smetzer (1998), one of the system failures, “staff inexperience and poor documentation had tremendously contributed to the sentinel event of the article” (p.49). When health care providers put their actions lower than their knowledge, practice without proper safety measures and documentation, then it affects

Safety is one of the most important traits of providing care to a patient. Medical mistakes are a growing concern within the health care field, as each year an estimated 400,000 lives are lost to preventable medical mistakes (James, 2013). One important subset of medical mistakes is medication errors. The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as “…any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer” (National Coordinating Council for Medication Error Reporting and Prevention, 2014). Health care

The human factor approach of Reason defines errors according to two types of failure: active and latent failure, with adverse events at times involving a combination of the two. Active failures are defines as “unsafe acts (i.e. errors and violations) committed by those at the human system interface”.20-22 Active errors occur at the level of the operator, and their effects are felt almost immediately. This is sometimes called the sharp end.20-22 Staff actions at the (sharp end) of patient care may involve slips (e.g. picking up the wrong syringe), cognitive failure (e.g. memory lapses or misreading of information), and violation (deviation from standard procedures or processes). Latent failures stem from decisions, essentially made by management and more senior clinicians within the healthcare setting, which provide conditions in which unsafe acts occur (e.g. inadequate system of communication; poor rostering of staff; inadequate supervision; understaffing) and also weakness in defenses (e.g.

Each flowchart step is placed in the “Lane” for the group responsible for completing the task (Marketing, Sales, HR, etc.).

I agree that the Dr. Ben D. and nurse Judy was inexperienced in pediatric patients. Was the nurse that Judy questioned an inexperienced nurse as well? I think this is a possibility since she did not reply that dosage was incorrect or advise her to verify the dosage. We can say there is an issue with inexperience; however, the answer is not placing blame on the staff. I would hope that the resident, nurses, and pharmacy would feel bad about the medication error and the danger in which the toddler was placed. I am concern that the physician and nurse did not know that a toddler’s potassium dose would not be the same as an adult.

Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error

develop a methodology for quantifying risks, or should each situation be addressed individually? Can we have both a quantitative and qualitative risk evaluation system in place at the same time?

Risk management is the term applied to a logical and systematic method of establishing the context, identifying, analyzing, evaluating, treating, monitoring and communicating risks associated with any activity, function or process in a way that will enable organizations to minimize losses and maximize opportunities. (Lecture notes)Risk Management is also described as 'all the things you need to do to make the future sufficiently certain'. (The NZ Society for Risk Management, 2001)

One well accepted description of risk management is the following: risk management is a systematic approach to setting the best course of action under uncertainty by identifying, assessing, understanding, acting on and communicating risk issues. In order to apply risk management effectively, it is vital that a risk management culture be developed. The risk management culture supports the overall vision, mission and objectives of an organization. Limits and boundaries are established and communicated concerning what are acceptable risk practices and outcomes. Since risk management is directed at uncertainty related to future events and outcomes, it is