CHILDREN’S HOSPITAL ISSUES & OPPORTUNITIES
Risk Assessment
In this case study the first step in risk assessment activities, which is the system characterization, the
scope of the effort is defined. The system-related mentioned in this case is the use of electronic infusion
pump. Dr. Ellington wrote an order for patient Matthew, a 10 year old patient, transferred from the
intensive care unit into his new room on the medical/surgical floor. Nurse Swenson instructed the newly
hired nurse, Patrick O’Reilly of Matthew’s medical condition at transfer and orders regarding the
electronic infusion pump to ensure that Matthew would receive his prescribed dosage of morphine. But
Nurse O’Reilly was not familiar with the said “electronic infusion pump”. Nurse O’Reilly had only
operated a pump during one training exercise. He asked for help from one of the nurses however the
nurses on the floor also did not know how to operate the pump due to the fact that patients from that
unit did not need a continuously infusion of painkillers.
The second step of the risk assessment activities is “threat identification”. The threat identification”
here was that no one was familiar with the electronic infusion pump. The situation had the possibility to
be life threatening to the patient. Nurse O’Reilly decided to ask for help to program the electronic
infusion pump that was ordered by Dr. Ellington and double check intravenous medications procedures.
Whenthe pharmacy delivered the electronic infusion pump to Matthew’s room the cassette tape
wasalready inserted and part of the label on the front of cassette was hidden. The hidden part of the
label contained important information. All of these factors contributed to the incident with the pump.
