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Running head: CHILDREN’S HOSPITAL AND CLINICS
CHILDREN’S HOSPITAL AND CLINICS
Harvard Business School
Eliza de Guzman, BSBA
National University – HTM 680: Health Informatics Case Study
Professor: Sary Beidas, MD, MBI, FACP
August 02, 2014
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Risk Assessment
In this case study the first step in risk assessment activities, which is the system
characterization, the scope of the effort is defined. The system-related mentioned in this case is
the use of electronic infusion pump. Dr. Ellington wrote an order for patient Matthew, a 10 year
old patient, transferred from the intensive care unit into his new room on the medical/surgical
floor. Nurse Swenson instructed the newly hired nurse, Patrick O’Reilly of Matthew’s medical
condition at transfer and orders regarding the electronic infusion pump to ensure that Matthew
would receive his prescribed dosage of morphine. But Nurse O’Reilly was not familiar with the
said “electronic infusion pump”. Nurse O’Reilly had only operated a pump during one training
exercise. He asked for help from one of the nurses however the nurses on the floor also did not
know how to operate the pump due to the fact that patients from that unit did not need a
continuously infusion of painkillers.
The second step of the risk assessment activities is “threat identification”. The threat
identification” here was that no one was familiar with the electronic infusion pump. The situation
had the possibility to be life threatening to the patient. Nurse O’Reilly decided to ask for help to
program the electronic infusion pump that was ordered by Dr. Ellington and double check
intravenous medications procedures. When the pharmacy delivered the electronic infusion pump
to Matthew’s room the cassette tape was already inserted and part of the label on the front of
cassette was hidden. The hidden part of the label contained important information. All of these
factors contributed to the incident with the pump.
The next step in risk assessment activities also apply to this case. The pump was set up to
administer the Morphine to the patient. Nurse O’Reilly was present and monitoring Matthew
when he recognized something was wrong and turn off the narcotic machine. He began
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ventilating the patient with a breathing bag and asked someone to call Dr. Ellington. When Dr.
Ellington arrived he administered a drug that reversed the effect of morphine, reviving the
patient. Once the patient was stable a review of the procedure was done. Dr. Chris gathered
everyone that was involved in providing care for Matthew. This group created a structured
problem-solving procedure to identify the causes of medical accidents and recognized the four
objectives: that helped them to understand what happen; to identify opportunities improvement;
to support the caregivers, patient, and family that were involved. The board of directors approved
Morath and Nelson’s plans to implement the patient safety initiative. The plan had three major
components: Culture; Infrastructure; and Medication Administration Project. Morath wanted to
transform the organizational culture to provide and environment conducive to discussing medical
accidents in a constructive manner. Second, the developing the infrastructure required to
implement safety improvements and a project was launched to overhaul the medication
administration system at the hospital. Morath has brought impassioned leadership to the hospital
for implementing patient safety that will help to reduce medical errors.
Five Rights of Medication Administration
One of the recommendations to reduce medication errors is to use the “five rights” which
are, the right patient, the right drug, the right dose, the right route, and the right time. In this case
we can say in the case above that the nurses involved did not complete the five rights. The case
stated that nurse Chen needed to enter both the morphine concentration and the appropriate rate
of infusion. The nurse did not see a concentration listed on the medication because it was on the
part of the label that was tucked inside the cassette. However, the nurse did utilize the
information on the part of the label that could be seen to calculate the concentration. All factors
contributed to patient Mathew’s case.
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Individual performance and not a human factors and system defects may make
completing the tasks difficult or impossible is the main focus of the five rights.
How are the medication administration risk different in a
Children’s hospital verses an Adult hospital?
Children’s Hospital is more at risk of medication administration than at an Adult’s
hospital. As the children are in the stage of the substantial changes in body proportions and
composition accompany growth and development. This process of maturation is one of the
differences between children and adults. During child development changes in body
composition and proportions are evident. There are other specific changes in organ function
during growth and maturation, which affect the pharmacokinetic characteristics of medicines at
different ages. There is an increased risk of medication errors in children because of the need to
make dosage calculations, which based on the patient’s weight, age or body surface area, and
their condition. For example, incorrect recording of patient’s weights may contribute to incorrect
dosing. While adult dosage are often formulated or suitable products prepared extemporaneously
in the pharmacy. This is one of the difference of risks of medication administration between
children’s and adult’s hospitals.
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References
Harvard Business School Case Study 9-302-050: Edmondson, A., Roberto, M.A., and Tucker, A.
- "Children's Hospital and Clinics"
The Five Rights of Medication Administration
http://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdministration.
aspx
Promoting Safety of Medicines for Children
http://www.who.int/medicines/publications/essentialmedicines/Promotion_safe_med_childrens.p
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