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hospitals and ambulatory care settings. This paper will be discussing and identifying risks
associated with medication administration, and providing some possible strategies that could be
considered when looking at the case study of the Childrens Hospital and Clinics in Minneapolis,
MN in 2001. Using the Five Rights of medication administration, we will look at how using
this method could help with the incident that caused a near-fatal event.
The event that occurred involved the administration of morphine to a ten year-old patient
at the Childrens Hospital and involved a group of nurses, some of them experienced and one
who was new to the staff. That event brought about the study into the incident and many other
medical accidents that had occurred at the clinic. Julie Morath, Chief Operating Office at the
Childrens Hospital, and her teams efforts were the focus of the case study. The issue that was
brought up during her study of the incident can be tied back to risk mitigation. Risk is a function
of the likelihood of a given threat-sources exercising a particular potential vulnerability, and the
resulting impact of that adverse event on the organization (Stoneburner, Goguen, & Feringa,
2002). It is critical for success and minimizing risk of an organization to take into consideration
the Five Rights of medication administration (Right patient, right drug, right dose, right route,
and right time). In addition to the Five Rights, we can also look at the 9-step risk assessment
As discussed in the NIST Publication (2002) by Stoneburner, Goguen, and Feringa, the
goal of this step is to analyze the controls that have been implemented, or are planned for
threats exercising a system vulnerability. By taking into account control methods, control
categories, and the control analysis technique, we are able to look into the Childrens Hospital
incident that occurred with medication administration and the ten year-old patients near fatal
occurrence.
Control method mentions the security controls being either technical or nontechnical. A
technical control would be a safeguard that is incorporated into a computer hardware, software,
or firmware. Nontechnical control would be management and operational controls like a security
policy, operational procedure, and personnel, physical, and environmental security. Under this
control method, we could consider the nontechnical controls that were in place that could have
prevented the morphine administration to the patient. The operational procedure and personnel
both had an impact on the morphine being administered incorrectly. The new nurse on the floor
and other nurses not being familiar with the infusion pump being used did not help with
administrating the right dose. If the nontechnical controls could have been checked ahead of
Preventative control aides in inhibiting attempt to violate security policy. Detective controls
helps to warn of violations or attempted violations of security policy. If we could take the
detective controls into consideration, auditors are able to go back in look back at the audit trails
that are created, as well as the checksums. If the new nurse, as well as the experienced nurses
who assisted, were trained, certified, and allowed to operate the pump via a badge reader that
was attached to the machinery, it would have prevented the use of the machine. Having a system
check in place in order to operate the pump may have helped with the incident. The nurses
would be able to verify that all Rights would be checked: patient, drug, dose, route, and time.
The next component of control analysis would be the technique, which is seen here by
their control environment, which would allow ensuring the validity of that checklist. Having an
updated checklist of the controls that are needed to be in place in regards to medication
administration and the use of electronic infusion pumps would help to create a safe environment.
addressed as well. There are various factors that differentiate administration of medication
between the two groups. Medication must have the appropriate dosages based on weight,
buffering factors, and making sure the dosages are based on child-sized dosages. What should
not be different would the controls that were discussed. All the same controls should be in place
in order to avoid any kind of medicine administration errors or at the very least, keep them to a
occur. Some say that we must take into consideration adding more Rights to the list. It is
important to take into account those basic Five Rights when administrating medication in any
type of environment. The risk assessments that are discussed by the National Institute of
Standards and Technology will aid in accomplishing and minimizing risk in health care settings.
References
Edmonston, A., Roberto, M. A., & Tucker, A. (2007). Childrens Hospital and Clinics (A).
Federico, F. (2016) The five rights of medication administration. Institute for Healthcare
fiverightsofmedicationadministration.aspx
Stoneburger, G., Goguen, A., & Feringa, A. (2002). Risk management guide for information
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