Portfolio Project Case Study

Portfolio Project Case Study
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Introduction
There are several factors that contribute to safety and medication errors within the health care system. Some of the factors that cause these errors are directly attributed to the organizations that are providing healthcare while others are attributed to the medication-use system. In most of the cases multiple factors are involved in these errors (Aspden, Wolcott, Bootman, & Cronenwett, 2007). The case study is an illustration of the complexities within the health care system and the process for medication usage and the inter-related nature of factors that are involved in the provision of quality and safe care (Aspden et al., 2007).
The physicians, nurses, and pharmacists of the hospital were not familiar with the treatment of congenital syphilis and had limited knowledge regarding the use of congenital syphilis drugs. The pharmacist that was filling the prescription made consultations with the infant progress notes. In the notes the nurse practitioner documented a recommendation for treatment for the health department (Aspden, Wolcott, Bootman, & Cronenwett, 2007). In addition, the pharmacist consulted a drug reference book and used it to determine the normal dose for penicillin G benzathine for infants. The pharmacist, however, erroneously read in both of the sources as 500,000 units/kilogram (kg), an adult dose instead of 50,000 units/kg (Aspden et al., 2007).
As a result, she misread the order as 1,500,000 units/kg since the "U" representing units was written as a zero hence added a zero to the dose. She prepared the dose as read and this was a 10 fold overdose. Due to the absence of constant pharmacy procedure for double checking this error went undetected (Aspden, Wolcott, Bootman, & Cronenwett, 2007). The label on the bag used for dispensing the drug indicated 2.5 milliliters (ml) of the prepared medication was to be administered intramuscularly (IM). This was to equal the 1,500,000 units/kg dose (Aspden et al., 2007). This dose led to the death of the patient.
The Role of a Risk Manager in Addressing the Case
Reducing risks and ensuring safety demand greater attention to the systems that are responsible for assisting in the prevention and mitigation of errors. Today, the popular quote "crossing the Chasm" provides suggestions that risk management and the improvement of quality efforts within healthcare organizations are pushing for patient safety and quality. In addition, establishing the means of effectively and efficiently working in an interdisciplinary manner to ensure organizations deliver safe and high-quality care (ECRI Institute, 2099).
Initiatives have been put in place that have forged alliances, and this began with the report by IOM in 1999 entitled "To Err Is Human: Building a Safer Health System." This emphasized the importance of health care organization to monitor from events arising from patient safety (ECRI Institute, 2099). According to ASHRM, the role of a risk manager has changed today. This survey indicated that the functions of a risk manager include risk identification and evaluation, prevention of loss, ensuring the safety of the patients, and education (ECRI Institute, 2099). Effective risk manage...