Risk Management Helps to Prevent Errors Essay - 1229 Words

Ways that the risk manager could prevent this type of event happening in the future would be to establish and maintain a functional pediatric formulary system with policies for drug evaluation, selection and therapeutic use. To prevent timing errors in medication administration, standardize how days are counted in all protocols by deciding upon a protocol start date. Limit the number of concentrations and dose strengths of high alert medications to the minimum needed to provide safe care. Assign a practitioner trained in pediatrics to any committee that is responsible for the oversight of medication management. Develop preprinted medication order forms and clinical pathways or protocols to reflect a standardized approach to†¦show more content†¦On the management side of the event would include: the charge nurse, director of the unit, risk manager, and the CEO of the organization. An event of this significance would catch the attention of numerous management staff, due t o the legal action that could be taken from the parents. The Joint Commission, Medication Errors Reporting program, and The National Council for Medication Error Reporting and Prevention would be the organizations involved to report the event to and aide in the prevention of it never happening again. This type of an event could catch the eye of the media. If the hospital were completely honest to the parents of the mistake, they could report it to the media for awareness of the fault of the organization, sympathy or education for prevent this event happening again. Active failures are the unsafe acts committed by people who are in direct contact with the patient or system. The forms vary but they are easier to pinpoint such as: slips, lapse, fumbles, mistakes, and procedural violations. Active failures have a direct and usually short lived impact on the integrity of the defenses (Reason, 2000). Active failures are the main issues that stand out when a risk happens. Latent co nditions are the inevitable â€Å"resident pathogens† within the system. They arise from decisions made by designers, builders, procedure writers and top level management. 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