Analyzing Risk with ERM - Research Paper Example

Topic: Analyzing Risk with ERM Introduction This paper presents a risk management process responding to a medication error in a healthcare organization. It highlights the identification, analysis, response and monitoring the risks and opportunities in the process within the internal and external environment facing the organization. The Strategic Objectives at Risk (SOAR) process has been applied when examining the process. This is a significant technique that helps in the accomplishment of strategic objectives. It exhaustively assesses the management of operational risks and also permits the manager to integrate ERM techniques in the organization. The methodology also allows risk managers to acquire better knowledge as regards the factors affecting the results of their activities concerned with the management of the gaining a better understanding of the factors that influence the outcomes of their actions relating to the management of the of organizational objectives. The process involves setting up of the standard measures in the particular strategic classes, observing the standard measurement values, analyzing their movements and eventually reacting to the results of the analysis. Medication Error Medication errors are likely to occur especially if there lacks effective communication between the doctors and the pharmacists in the healthcare organization. There are situations whereby the wrong prescriptions are given by the physicians either by mistake, incompetence among healthcare workers or negligence. According to Jcaho (2007), “problems have in the past been detected by pharmacists in the process of dispensing drugs”. Some prescriptions are usually not precise while others have reflected the wrong dosage. There are also cases where patients receive prescriptions while taking other drugs. Some of the drugs may be harmful once they interact in the body, and many other problems such as contraindications. The common types of medication errors include prescribing a wrong dose to the patient especially for the drugs that have almost similar names or those that have almost similar packaging. Prescribing the wrong drug is also a common problem especially following the wrong diagnosis, while it is also common for healthcare workers to administer the drug through the wrong route. Interruptions when prescribing medicine are also a major cause of medication errors (Thompson and Davidow, 2009). The organization may loose its reputation as a result of the medication errors, which may lead to the loss of confidence among clients. On the other hand, the patients are protected by the law against medical malpractices and they may file legal claims against the organization. The consequences may be detrimental to the organization especially if it is compelled to compensate patients due to damages. More so, the loss of clients decreases the organization’s competitiveness in the market (Kaplan, 1999). It is therefore important to put measures in place to prevent such errors from occurring in the organization. Response to the Risk A risk management process is needed to respond to the issue of medication errors. First, it is important to set objectives of controlling medication errors. These will involve ensuring that the right personnel are involved in giving the prescriptions. The knowledge required in dispensing medications is extensive and this activity needs skilled people who have undergone sufficient training. Without this kind of knowledge, it is likely that errors will be made and the consequences may be detrimental to the patients. A qualified pharmacist is needed to help in ensuring that patients receive the desired medication. In order for dispensing prescriptions to be effective in the organization, it is important to ensure that the initial stages of procurement are carefully conducted. The drugs should be procured under the supervision of qualified healthcare personnel, most probably pharmacists. Having extensive knowledge in regard to the patient’s response to various drugs, the person has a role to play in ensuring that the drugs offered to patients are of the best quality. The pharmacist needs to be in charge of developing a care plan for dispensing medications as well as reports on the anticipated results as regards the patient’s health. In case of failures in the effectiveness of prescriptions, it is the responsibility of the pharmacist to offer advice to the physician on the possible alternative drugs available to serve the same purpose. He/she should also be responsible for ensuring that expired drugs are not supplied to the patients (Thompson and Davidow, 2009). With the strategic objectives in place, it is important to set the standards of measuring performance as defined in Strategic Objectives at Risk (SOAR) process (Monahan, 2008). The metrics in this situation need to be the competence of staff as regards prescribing and dispensing medication. These can be known through the response of the patients regarding the effectiveness of the medications. The metrics can also include the number of errors that are identified in medications, which are significant indicators of the improvements of failures in prescriptions within the organization. It is also important to ensure that the drugs procured by the organization are accompanied with prescription documents that are readable. They should also be labeled appropriately to ensure that confusion between drugs with nearly similar names is avoided. The prescription orders need to have clear information regarding the purpose of the drug for the intention of safety checks when offering prescriptions for the drug. The metric system should be used for all the prescription orders unless if the medication is applied on a standard scale. Initials should be avoided in prescriptions. Rather, the full name of medication should be used. Whenever procuring medication, it is important to ensure that the appropriate age is indicated on them. A qualified pharmacist should be involved in the procurement process to ensure that all the necessary information is available. It is important to ensure that all numbers that are less than one are preceded by a leading zero. On the other hand, the end of a value should not be succeeded by zeroes. The instructions should be precise and to the point. Unclear and open-ended statements should not be used. There should be a reference list for the medications used for various diseases to avoid the pharmacists making guesses regarding the prescriptions. On the other hand, a list of the high alert drugs should be developed so that awareness can be increased among pharmacists and other staff involved in dispensing and prescribing medication. These standards need to be observed to ensure that the organization is in constant watch of any impending risks (Lam, 2003). Monitoring the risks and the adherence to the standards of performance is important to ensure that the organization is protected from malpractices as regards prescription of medications. Strategies for monitoring include random assessment of the prescriptions given to patients from the organization to ascertain that they are correct. The patient’s feedbacks are also significant in providing information regarding the consequences of medications prescribed by the organization’s staff. It is important to adhere to the prescribing process to ensure that all the medications recommended for the patients are given through a uniform process that is understood among all staff. The monitoring team will be checking the adherence to the prescribing process by the staff. The process involves recognizing a problem in the patient and assessing to understand the nature, onset and other aspects of the ailment. The healthcare personnel should then identify the need to administer treatment to the patient. They must be qualified to determine the appropriate treatment to be administered to the patient. Monitoring should include regularly checking the medication orders and the readability of the handwritten instructions as well as the dosage. The faulty instructions that do not follow the prescription process should not be passed on to patients (Thompson and Davidow, 2009). A multi-disciplinary approach to monitoring should be used, which needs to involve healthcare professionals in medicine, pharmacy and nursing. They should be knowledgeable regarding the symptoms of adverse consequences of drugs. When such an event is identified, the process of prescription should be evaluated against the metrics set for medication. The metric values should be observed as stated in SOAR process to identify the disparities in medication. These values offer guidelines leading to the identification of problems in medication. They are the standards that any healthcare professional administering medication in the organization should have in mind. Observing the metric values is significant for the organization to maintain focus on the accomplishment of the strategic objectives (Monahan, 2008). Movement of the metric values is an anticipated occurrence in the organization and should be analyzed to boost evaluation efforts. Analyzing these movements allows the monitoring team to develop strategies to control medication errors. For example, in spite of the organization’s efforts to ensure that the personnel in charge of medications are qualified, there might be situations whereby replacement is required as a result of externalities. This means that the metrics of medication may be affected and hence the monitoring team has to ensure that the movements are understood and the appropriate action taken. The external environment presents a major drawback especially if there happens to be changes in medications as a result of research, new discoveries and improvements in the healthcare system. These may disorganize the standards that have been set as the metrics of medication. For example, Abood (2005) observes that there are many cases whereby drugs that have been administered to patients for a long time are found to be inappropriate or having adverse side effects leading to their invalidation from treating diseases. This is among the externalities that the monitoring team has to be prepared to deal with. Other environmental factors include the emergence of new drugs that are regarded as superior to the existing ones. The healthcare professionals are likely to be influenced by a sudden wave in the medical field whereby the new drug is widely accepted. The metrics of the organization need to be observed even when changing from the use of one drug to the other (Hubbard, 2009). Reacting to the analysis of the metrics is the final step as defined in the SOAR process. The findings are significant in enhancing accuracy of medication as well as development of strategies for accomplishment of the organization’s objectives. For example, the realization that medication errors arise as a result of the presence of unqualified people among the healthcare personnel leads to a careful choice of the staff to be in charge of prescribing medications. Reactions are also case sensitive and can be useful in solving adverse cases that could increase risks in the organization (Lam, 2003). For example, if a particular case has been identified and the cause established to be negligence among the healthcare professionals, the reaction to such analysis can be to change the working structure to ensure that the responsible people are replaced by others, who are qualified and also to develop measures that prevent any future occurrence of such problems. Reaction may also involve identifying the areas that need changes as regards the prescription process. With new discoveries in healthcare, the obsolete procedures need to be done away with and new ones adopted to match the changing needs of patients. On the other hand, understanding the competitors is important especially due to the fact that they focus on capitalizing in organization’s weaknesses. On the other hand, damage control is significant to ensure that the organization does not loose its reputation. This involves calling back the clients and offering remedy to the upcoming issues regarding medication errors (Kaplan & Norton, 2001). Conclusion Lack of effective communication among the healthcare professionals in the organization may lead to uncontrolled medication errors. Such errors may affect the organization’s reputation, which is the reason why a risk management process is necessary to control medication errors. Prescribing and dispensing medication needs to be the responsibility of qualified personnel. Metrics should be set for effective accomplishment of the strategic objectives. Risk monitoring is significant to enhance adherence to the set standards of performance as regards prescribing the medications. It is a process that needs to be undertaken through a multi-disciplinary approach whereby professionals from various fields such as pharmacy, nursing and medicine are involved. Reacting to the analysis of the metrics is a significant step in controlling medication errors. References Abood R. (2005). Pharmacy Practice and the Law, Jones and Bartlett Publishers, Inc. Hubbard, D. W. (2009). The Failure of Risk Management: Why It's Broken and How to Fix It, Wiley  Kaplan, R. S. (1999). Translating strategy into action. Cambridge, MA: Renaissance Solutions. Kaplan, R. S., & Norton, D. (2001). The strategy focused organization: How Balanced Scorecard companies strive in the new business environment. Boston, MA. Harvard Business School Publishing Corporation. Jcaho J. (2007). The Pharmacist's Role in Patient Safety, Joint Commission Resources. Lam, J. (2003). Enterprise Risk Management: From Incentives to Controls, Wiley Monahan, G. (2008). Enterprise Risk Management: A Methodology for Achieving Strategic Objectives, John Wiley & Sons Thompson, J. and Davidow, L. (2009). A Practical Guide to Contemporary Pharmacy Practice, Lippincott Williams & Wilkins. Read More