Risk Managemnt

Risk Management Paper

Risk management is one way to help ensure quality throughout the organization. According to Sullivan and Decker, "risk management is a program directed toward identifying, evaluating, and taking corrective action against potential risks that could lead to injury of patients, staff, or visitors" (2005, pp 187). Risk management is a problem-focused program to prevent loss and control liability. It identifies risks for injury then develops a plan to reduce injury and accidents. Examples of risk include medication errors, incidents related to diagnostic procedures, medical-legal incidents such as refusal of treatment, falls, and patient or family dissatisfaction with care (Sullivan and Decker, 2005). Medication errors are high-risk and can be detrimental to the patient. At Children's Hospital of Philadelphia (CHOP), a current risk management issue is medication errors related to continuous infusions.

Medication Errors

P. King (personal communication, April 20, 2007) is a charge nurse on the Cardiothoracic Intensive Care Unit (CTICU). She is also responsible for reviewing all incident reports on the unit. In discussing the incident reports, it is determined that many are related to errors with continuous infusions. One example she provides is incorrect concentrations of infusions, such as inotropes, Lasix and narcotics, being hung. A second example of reportable incidents she provides is incorrect programming of the infusion pumps. This can be related to incorrectly programming the dose of medication, the correct concentration of the medication, or the patient's weight. These two examples are due to errors by the bedside nurse. However, errors can also occur when the physician enters the infusion order or when the pharmacist prepares the infusion. All these reportable instances can cause the patient to receive the wrong amount of medication, which can be detrimental to their health.

Addressing the Issue

According to P.King, addressing the issue of medication errors related to continuous infusions can be difficult. Errors can result from several breakdowns in the system. In order to effectively manage this risk, all the areas of breakdown must be addressed. Steps currently being taken at CHOP include encouraging reporting of incidents, utilizing standard concentrations for medications, and instituting a two nurse check for continuous infusions. A computerized order entry system is also used to help decrease the errors made during order entry.

Encourage Reporting of Incidents

In order to determine the frequency, severity, and causes of the errors, incident reports must be completed. Incident reports must be completed for any unplanned event that affects or could affect a patient, visitor, or staff member. Not all reportable incidents result in the completion of an incident report. The main reason for not completing an incident report is fear of the consequences (Sullivan and Decker, 2005). According to P. King, incident reports completed at CHOP, incident reports are never used for punishment. During orientation, staff members receive a lecture from the risk manager regarding the use of incident reports. The risk manager emphasizes that the incident reports are used to identify problems within the delivery system and not to penalize any employee. Staff is encouraged to complete an incident report for all reportable incidents.

Utilization of Standard Concentration

P. King explains that CHOP has recently initiated a change to the use of standard concentrations for infusions. In the recent past, the nurses were responsible for mixing all continuous infusions. The concentration of the infusions differed for each patient based on his weight. The hospital is now using standardized concentrations for most inotropes and sedation medications. These infusions are made by the pharmacists. By using standardized concentrations, the hospital has cut down on infusion errors related to incorrect concentrations. The nurses are still responsible for mixing some infusions, such as Lasix, Calcium Chloride, and Vasopressin.

Two-Nurse Check for Infusions

According to P. King, another step in place to reduce medication errors with continuous infusions is the initiation of a two-nurse check. When a nurse is mixing an infusion, she must have the calculations and medication amount double checked with a second nurse. The second nurse must initial the medication label, acknowledging that she checked the infusion. The second nurse must also check that the pump had been programmed correctly.

Computerized Order Entry System

CHOP uses a computerized order entry system. This system helps to decrease the number of errors that take place during the order entry phase. When the physician enters an order for a continuous infusion, the computerized system offers recommended dosing, the patient's weight in kilograms, and suggested standardized concentrations for the patient's weight. This program decreases errors related to ordering a wrong dose and to the chance of the nurse misreading the order.

Development of the Remedy

P. Simonson (personal communication, April 19, 2007) is the clinical nurse manager of the CICU. She helps initiate strategies in the CICU to reduce infusion errors. According to P. Simonson, the first step in developing a remedy was to review and trend all incident reports related to continuous infusion errors with the CHOP risk manager. Upon reviewing the incident reports, they found that the most common causes of error were improper mixing of infusion