Hospital Risk Management Essay

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Portfolio Project on Hospital Risk Management

Read and carefully analyze the case study which is attached above.

Prepare a scholarly composition using references to support your thoughts and ideas.  Denote the source of information included in your paper. Your paper should address the following points in an academic tone:

  • A risk manager’s role in addressing the events described in the case study. The Joint Commission requirements for reporting sentinel events for a hospital
  • Steps a risk manager must take to address these events
  • Processes and techniques that a risk manager would take to investigate, prevent, and control these types of events now and in the future
  • Internal and external individuals and entities that might be involved in this situation, why, and in what capacity
  • The practicality and implications of one or more theories on accident causation
  • Measures to assess the performance of the organization and the risk management plan in this area as it relates to patient care and compliance
  • Impact these events could have on organizational performance, compliance, and accreditation

Include at least six references, two of which must be scholarly articles (which can be accessed from the CSU Global Virtual Library).

Here’s a snippet of the essay.


Numerous factors in the healthcare system may contribute to medical safety and errors. Some of these factors may be attributed directly to provider organizations, while others would be attributed to the medical-use system itself. In many cases, multiple factors contribute to the same. The case study presented in this paper illustrates the complexity of the healthcare system and the medical processes, and the interrelatedness of the factors involved in medical safety and quality.


Case Analysis

The medical error involved here led to the death of an infant born to a mother with a previous history of syphilis. The communication process had been hampered by the fact that the mother would only speak Spanish.  Despite insufficient information regarding past treatment accorded to the mother, a decision is made to treat the infant for congenital syphilis. After a telephone consultation with specialists and the healthcare department, an order of “Benzathine penicicillin G 150,000UIM” was made. The hospital physicians, pharmacists, and nurses with limited knowledge about this drug, portrayed lack of experience in treating congenital syphilis. The nurse may have used both the child’s progress notes and a drug reference book to determine the recommended dosage of penicillin G Benzathine for an infant. However, the pharmacists misread the dosage from both sources as 500,000 units/kg instead of 50,000 units/Kg. This dose would be recommended for a typical adult.  The order was made and a 10-fold overdose was delivered. The hospital did not have a sufficient pharmacy procedure for double-checking; therefore, the error was not detected. A pharmacy label on the container indicated that 2.5 milliliters of the medicine would be administered intramuscularly (IM) to equal a dosage of 1,500,000 units.


After concerns over the pain that administering the drug IM would inflict on the child, the nurses sourced the possibility of administering the drug intravenously (IV), however, the medical reference book did not indicate whether penicillin G benzathine could be administered IV. The neonatal nurse overlooked the hospital policies and practices that did not clearly define prescribing authority in terms of the ability to change prescription orders, instead, the nurse assumed that she was operating within the confines of a national protocol that allowed the practitioners to plan, direct, implement, and change drug therapy. Consequently, she made a decision to administer the drug IV.

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