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Children’s Hospital and Clinics Week 4 Written Assignment Mariah Delaire HTM 680 Dr. Sary Beidas
July 30, 2016
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Children’s Hospital and Clinics: Week 4 Written Assignment Hospitals and health care facilities are the places individuals go to receive care to help their overall health. Unfortunately, nearly 251,000 lives are lost each year due to medical errors that take place in these facilities, making it the thirdleading cause of death in the United States (Cha, 2016). A medical error is a preventable event of care which can include incomplete treatment or medication errors. These errors not only contribute to loss of life but also contribute to loss of trust in the health care system, which results in lower satisfaction by patients and health care professionals (Institute of Medicine , 1999). It has been observed that these errors are more commonly caused by faulty systems, processes, and conditions, creating mistakes. Taking the necessary steps to prevent these errors and improve patient safety is essential in health care to become more aware of the risks that are present. On January 5, 2001 in the Medical/Surgical unit at Children’s Hospital and Clinics in Minneapolis, an incident occurred that could have very easily ended with a loss of life due to a medical error. Dr. Ellington wrote an order for 0.8 milligrams per hour of morphine. Nurse Patrick O’Reilly was left alone by his preceptor to set the smart IV pump for infusion of the morphine. Unfortunately, O’Reilly was unfamiliar with how to operate the pump, as were the other staff members in that unit, and didn’t take into account that children differ from adults when it comes to medication. They are much smaller than adults, so larger doses can have detrimental effects. Due to the lack of education and incompetence, the pump was set incorrectly resulting in the tenyearold patient to overdose on morphine, sending him into respiratory arrest. Luckily the physician was nearby who administered a reversal agent allowing the patient to survive the incident. Medical errors like the one that occurred at Children’s Hospital occur every day, and can be easily preventable with the help of a risk management methodology. Risk management is the process of identifying risk, assessing risk, and taking the necessary steps to reduce the risk. The principle of this process is to protect the organization and its ability to perform their mission (Stoneburner, et al, 2002).
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Risk management focuses on three processes which include risk assessment, risk mitigation, and evaluation and assessment (Stoneburner, et al, 2002). Some of the reasons an organization would take on a risk management assessment would be to minimize the negative impact on an organization and the need for sound decision making. Risk assessment plays an important role in the risk management methodology. This tactic is used to determine the extent of the potential threat and the risks associated with an IT system throughout (Stoneburner, et al, 2002). Risk assessments encompass nine steps that are used to measure the level of impact IT assets have on an organization. One of the steps in the risk assessment phase that is instrumental in identifying and preventing risks is Step 3: Vulnerability Identification. The goal of vulnerability identification is to develop a list of system flaws or weaknesses that could be exposed by potential threats. Searching for vulnerabilities are based on the nature of the IT system. For instance, if a system is not yet designed, the search should focus on the organization’s security policies, procedures and system requirements. If the system is already implemented, the search should be expanded to include more information such as the planned security features. Lastly, if the system is operational, the process should include an analysis of the system features, controls, and technical features used to protect the system (Stoneburner, et al, 2002). In the case of Children’s Hospital, the electronic IV infusion pumps lacked safeguards that should have been in place to ensure that overdosing doesn’t occur, such as entering a patient age or weight with a max dosage. Unfortunately, these systems do not take into account the five patient rights of medication administration, which are the right patient, right drug, right dose, right route at the right time. If the pump system was integrated with the five rights, perhaps medication errors could be prevented. Informationgathering techniques such as questionnaires, onsite interviews, and document reviews are also essential in identifying vulnerabilities. Gathering information in the case of the electronic IV pumps to assess the potential vulnerabilities could have potentially prevented the incident at
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Children’s Hospital. These tools could be used to collect information concerning management and operational controls of the IV pumps. System security is a proactive method that can be utilized to identify vulnerabilities as well. Some of the tests include automated vulnerability scanning tools, security test and evaluation, and penetration testing (Stoneburner, et al, 2002). Security testing and evaluation is the most applicable strategy in the case of Children’s Hospital. ST&E includes the development and execution of a test plan to test the effectiveness of the security controls of an IT system. This strategy is important when testing new systems, such as an electronic IV pump. Had it been properly tested in a controlled environment with multiple scenarios, vulnerabilities, such as the lack of training, could have been assessed. Once assessed, competencies can be created for staff which ensures that questions are addressed and errors are prevented. Medical errors occur every day but can be easily prevented by recognizing the potential issues and determining the most appropriate ways to avoid them. One of the ways this can be done is utilizing a risk management methodology. Children’s Hospital and Clinics didn’t take the steps that were necessary to avoid a very preventable error during routine patient care. Had a risk assessment been done when implementing the electronic IV pumps, issues associated with it could have been identified and addressed. Some of the issues that should have been identified were the lack of safeguards/security controls in the system itself and the lack of staff training in multiple scenarios. Using a risk assessment methodology to assess threats and vulnerabilities in an IT system is critical in determining the likelihood of future adverse events. Determining these potential events allows an organization to be more aware and creates a culture of safety because appropriate actions are being taken every day to ensure incidents do not occur.
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References Cha, A. E. (2016, May 3). Researchers: Medical errors now third leading cause of death in United States. Retrieved from The Washington Post: https://www.washingtonpost.com/news/toyour health/wp/2016/05/03/researchersmedicalerrorsnowthirdleadingcauseofdeathinunited states/ Institute of Medicine . (1999). To Err is Human: Building a Safer Health System. National Academy of Sciences. Stoneburner, G., Goguen, A., & Feringa, A. (2002). Risk Management Guide for Information Technology Systems. Gaithersburg, MD: National Institute of Standards and Technology.
