Running head: CHILDRENS HOSPITAL AND CLINICS

ChildrensHospitalandClinicsWeek4WrittenAssignment
MariahDelaire
HTM680
Dr.SaryBeidas

July30,2016

CHILDRENS HOSPITAL AND CLINICS

ChildrensHospitalandClinics:Week4WrittenAssignment
Hospitalsandhealthcarefacilitiesaretheplacesindividualsgotoreceivecaretohelptheir
overallhealth.Unfortunately,nearly251,000livesarelosteachyearduetomedicalerrorsthattakeplace
inthesefacilities,makingitthethirdleadingcauseofdeathintheUnitedStates(Cha,2016).Amedical
errorisapreventableeventofcarewhichcanincludeincompletetreatmentormedicationerrors.These
errorsnotonlycontributetolossoflifebutalsocontributetolossoftrustinthehealthcaresystem,
whichresultsinlowersatisfactionbypatientsandhealthcareprofessionals(InstituteofMedicine,
1999).Ithasbeenobservedthattheseerrorsaremorecommonlycausedbyfaultysystems,processes,
andconditions,creatingmistakes.Takingthenecessarystepstopreventtheseerrorsandimprovepatient
safetyisessentialinhealthcaretobecomemoreawareoftherisksthatarepresent.
OnJanuary5,2001intheMedical/SurgicalunitatChildrensHospitalandClinicsin
Minneapolis,anincidentoccurredthatcouldhaveveryeasilyendedwithalossoflifeduetoamedical
error.Dr.Ellingtonwroteanorderfor0.8milligramsperhourofmorphine.NursePatrickOReillywas
leftalonebyhispreceptortosetthesmartIVpumpforinfusionofthemorphine.Unfortunately,OReilly
wasunfamiliarwithhowtooperatethepump,asweretheotherstaffmembersinthatunit,anddidnt
takeintoaccountthatchildrendifferfromadultswhenitcomestomedication.Theyaremuchsmaller
thanadults,solargerdosescanhavedetrimentaleffects.Duetothelackofeducationandincompetence,
thepumpwassetincorrectlyresultinginthetenyearoldpatienttooverdoseonmorphine,sendinghim
intorespiratoryarrest.Luckilythephysicianwasnearbywhoadministeredareversalagentallowingthe
patienttosurvivetheincident.
MedicalerrorsliketheonethatoccurredatChildrensHospitaloccureveryday,andcanbe
easilypreventablewiththehelpofariskmanagementmethodology.Riskmanagementistheprocessof
identifyingrisk,assessingrisk,andtakingthenecessarystepstoreducetherisk.Theprincipleofthis
processistoprotecttheorganizationanditsabilitytoperformtheirmission(Stoneburner,etal,2002).

CHILDRENS HOSPITAL AND CLINICS

Riskmanagementfocusesonthreeprocesseswhichincluderiskassessment,riskmitigation,and
evaluationandassessment(Stoneburner,etal,2002).Someofthereasonsanorganizationwouldtakeon
ariskmanagementassessmentwouldbetominimizethenegativeimpactonanorganizationandtheneed
forsounddecisionmaking.Riskassessmentplaysanimportantroleintheriskmanagement
methodology.Thistacticisusedtodeterminetheextentofthepotentialthreatandtherisksassociated
withanITsystemthroughout(Stoneburner,etal,2002).Riskassessmentsencompassninestepsthatare
usedtomeasurethelevelofimpactITassetshaveonanorganization.Oneofthestepsintherisk
assessmentphasethatisinstrumentalinidentifyingandpreventingrisksisStep3:Vulnerability
Identification.
Thegoalofvulnerabilityidentificationistodevelopalistofsystemflawsorweaknessesthat
couldbeexposedbypotentialthreats.SearchingforvulnerabilitiesarebasedonthenatureoftheIT
system.Forinstance,ifasystemisnotyetdesigned,thesearchshouldfocusontheorganizations
securitypolicies,proceduresandsystemrequirements.Ifthesystemisalreadyimplemented,thesearch
shouldbeexpandedtoincludemoreinformationsuchastheplannedsecurityfeatures.Lastly,ifthe
systemisoperational,theprocessshouldincludeananalysisofthesystemfeatures,controls,and
technicalfeaturesusedtoprotectthesystem(Stoneburner,etal,2002).InthecaseofChildrensHospital,
theelectronicIVinfusionpumpslackedsafeguardsthatshouldhavebeeninplacetoensurethat
overdosingdoesntoccur,suchasenteringapatientageorweightwithamaxdosage.Unfortunately,
thesesystemsdonottakeintoaccountthefivepatientrightsofmedicationadministration,whicharethe
rightpatient,rightdrug,rightdose,rightrouteattherighttime.Ifthepumpsystemwasintegratedwith
thefiverights,perhapsmedicationerrorscouldbeprevented.
Informationgatheringtechniquessuchasquestionnaires,onsiteinterviews,anddocument
reviewsarealsoessentialinidentifyingvulnerabilities.Gatheringinformationinthecaseofthe
electronicIVpumpstoassessthepotentialvulnerabilitiescouldhavepotentiallypreventedtheincidentat

CHILDRENS HOSPITAL AND CLINICS

ChildrensHospital.Thesetoolscouldbeusedtocollectinformationconcerningmanagementand
operationalcontrolsoftheIVpumps.Systemsecurityisaproactivemethodthatcanbeutilizedto
identifyvulnerabilitiesaswell.Someofthetestsincludeautomatedvulnerabilityscanningtools,security
testandevaluation,andpenetrationtesting(Stoneburner,etal,2002).Securitytestingandevaluationis
themostapplicablestrategyinthecaseofChildrensHospital.ST&Eincludesthedevelopmentand
executionofatestplantotesttheeffectivenessofthesecuritycontrolsofanITsystem.Thisstrategyis
importantwhentestingnewsystems,suchasanelectronicIVpump.Haditbeenproperlytestedina
controlledenvironmentwithmultiplescenarios,vulnerabilities,suchasthelackoftraining,couldhave
beenassessed.Onceassessed,competenciescanbecreatedforstaffwhichensuresthatquestionsare
addressedanderrorsareprevented.
Medicalerrorsoccureverydaybutcanbeeasilypreventedbyrecognizingthepotentialissues
anddeterminingthemostappropriatewaystoavoidthem.Oneofthewaysthiscanbedoneisutilizinga
riskmanagementmethodology.ChildrensHospitalandClinicsdidnttakethestepsthatwerenecessary
toavoidaverypreventableerrorduringroutinepatientcare.Hadariskassessmentbeendonewhen
implementingtheelectronicIVpumps,issuesassociatedwithitcouldhavebeenidentifiedand
addressed.Someoftheissuesthatshouldhavebeenidentifiedwerethelackofsafeguards/security
controlsinthesystemitselfandthelackofstafftraininginmultiplescenarios.Usingariskassessment
methodologytoassessthreatsandvulnerabilitiesinanITsystemiscriticalindeterminingthelikelihood
offutureadverseevents.Determiningthesepotentialeventsallowsanorganizationtobemoreawareand
createsacultureofsafetybecauseappropriateactionsarebeingtakeneverydaytoensureincidentsdo
notoccur.

CHILDRENS HOSPITAL AND CLINICS

References
Cha,A.E.(2016,May3).Researchers:MedicalerrorsnowthirdleadingcauseofdeathinUnited
States.RetrievedfromTheWashingtonPost:https://www.washingtonpost.com/news/toyour
health/wp/2016/05/03/researchersmedicalerrorsnowthirdleadingcauseofdeathinunited
states/
InstituteofMedicine.(1999).ToErrisHuman:BuildingaSaferHealthSystem.NationalAcademyof
Sciences.
Stoneburner,G.,Goguen,A.,&Feringa,A.(2002).RiskManagementGuideforInformationTechnology
Systems.Gaithersburg,MD:NationalInstituteofStandardsandTechnology.