Running head: Medication Administration Risk Assessment

Medication Administration Risk Assessment

Edwin J. Ocasio
National University
COH 680: Health Informatics Case Study
Submitted to Dr. Sary Beidas
January 31, 2015

Medication Administration Risk Assessment

Medication Administration Risk Assessment
Childrens Hospital and Clinics (Childrens) formed in 1994. By 2001, Childrens
provided medical services for infants, children, and adolescents in six facilities. On January 5,
2001, a critical error occurred at Childrens Hospital. A ten-year old patient received an infusion
of morphine that almost killed him. The quick actions of a nursing school graduate and attending
physician saved his life. They recognized the medication error and administered an antidote. The
drug reversed the effects of the morphine. A short time later, the patient was breathing normal
and made a full recovery. At first it was unclear what had happened. But after a focused event
analysis, the hospital leadership documented the cause. The document listed the events that led
up to the morphine overdose incident. The Associate Director of Medical Affairs attributed the
success of the analysis to the ground rules set for the discussion. The facilitator stated that it was
a blameless environment that would focused on finding the failures of the patient safety system.
He added that the process would be confidential. It would be an opportunity to improve on the
hospitals safety systems and processes.
Julie Morath became the Chief Operating Officer of Childrens Hospital in May of 1999.
She led the effort to address patient safety. This was a part of the hospitals strategic plan. The
plan had three main elements. Transform the organizational culture in discussing medical
accidents in a constructive and conducive environment. The second element was to develop the
infrastructure to implement safety improvements. Third element would be to overhaul the
medication administration system at the hospital. She decided to use the National Institute of
Standards and Technology (NIST) paper methodology. Morath began to identify risks associated
with medication administration. She estimated the likelihood of each risk. And she developed a
risk mitigation strategy applicable to patient safety at Childrens.

Medication Administration Risk Assessment

NIST assessment requires nine steps, some of which can occur in parallel after the first
step is complete. This first step determines the systems characteristics. It includes the process
starting with the physician prescribing a drug. It concludes when the patient receives the
medication. It lists all the equipment, tools and materials used to administer the medications. It
focuses on each individual transfer of information or responsibility of medicine administration.
The medical staff are careful, safe, and have proceeded with great amount of precision. The Six
Rights of Safe Medication Administration identify the threats to patient safety. It ensures that
you have the right patient, right medication, right dose, right time and the right route. Then the
staff makes right documentation in the patients record.
The source of each safety threat is as important as the threat itself. It can be the
manufacturer, the label, the dosage or strength of the medication. The process of ordering,
mixing and preparing drugs is an unexpected sources of threats. The supplies, equipment, and
personnel usually are at fault for many of the errors. The organization must monitor the as a
threat. Many of the procedures for administrating medication are vulnerable to errors. Staff
should keep them in check. Administering medications to children requires extra caution.
Dosages for children are usually determined on the adults equivalent. Health care organization
buys adult dosages of medication to save money. It reduces the number of different dosages
stored. They measure the dosage for a child based on their weight.
A control analysis is a crucial step in documenting the current and planned controls. It
should include a determination of the likelihood that the controls are in place. They must
validate their adherence. They must also focus emphasis on the impact of not adhering to these
controls. The impact analysis must detail the effects it will have on the patient, the staff, and the

Medication Administration Risk Assessment

organization. Along with the impact, the risk for non-adherence must be determine. The level or
magnitude of the risk are weigh against the adequacy of the controls. It will compare those that
are in placed or planned. The leadership will review new controls required as the results of the
analysis. They will make recommendations for changes in any or all phases of medicine
administration.
Control actions must focus on the greatest risk, the impact, and the cost of
implementation. All control actions should rank and assign responsible persons to assure
adherence. The controls plans will serve as safeguards to reduce the risk. There may also be
some type of residual risk. Everyone is the responsibility for monitoring risk. The leaders of the
organization must transform the patient safety and risk assessment culture. All stakeholders must
execute risk assessment and patient safety practices.
Risk mitigation involves prioritizing, evaluating, and implementing the appropriate riskreducing controls. They should extract the data from the recommended risk assessment process.
It may be unlikely to eliminate all risk. It is the responsibility of leadership to use the least-cost
approach and implement the most appropriate controls. It should decrease medication errors. It
must focus on calculation errors, dilution errors, wrong route, rate and patient determination, and
lack of information at the point of use. There is always an assumption that an error can occur.
The organization could also avoid or limit the risk. Risk planning can identify the potential for
errors, their impact and approaches for mitigation. A risk mitigation strategy provides guidance
on threats, vulnerabilities and the impact of errors.
The risk management team documents the results in an official report or briefing. The
risk assessment report helps senior management make strategic decisions. They will affect
policy, procedural, budgetary, and system operations and management changes. They are unlike

Medication Administration Risk Assessment

an audit or investigation report. It does not look for wrongdoing. The risk assessment report
should not be accusatory. It should be a systematic and analytical approach to assessing risk.
Senior management understands the risks and provide resources to reduce and correct potential
losses. This threat/vulnerability pair is an observation not a finding.

Medication Administration Risk Assessment

References
Stoneburner, G., Goguen, A., and Feringa, A. (2002). Risk management guide for information
technology systems. National Institute of Standards and Technology. Retrieved from
http://csrc.nist.gov/publications/PubsSPs.html#800-30.
Edmondson, A., Roberto, M.A., and Tucker, A. (2007). "Children's Hospital and Clinics"
Harvard Business School Case Study 9-302-050.

Medication Administration Risk Assessment