Risk Management in Long Term Care

Within the culture of the St. John Health System (SJHS), risk management is considered the responsibility of every SJHS associate, from the CEO to the maintenance man. Each associate has an obligation to perform their jobs safely and to eliminate or at least minimize the risk of harm to any resident, visitor, or employee. The collection and utilization of data is also essential to a successful risk management program. Effective risk managers recognize the importance of data which may be used to identify residents at risk for falls, wounds, and infections for instance.
When carefully collected and analyzed, this information may help the LTC manager identify at risk residents and target the resources needed to address their issues. Sources of data include the minimum data set (MDS) that provides information about residents resulting from multidisciplinary assessments. This information is also used for Medicare reimbursement, standards that identify the facility’s quality of care, and for state surveyors to review (McKnight’s, 2013).
Federal and state rules and regulations such as OSHA, incident reports, nurse’s notes, and physician progress notes are some of the other documentation risk managers analyze (Sullivan, 2013). In 1998, St. John Senior Community (SJSC) had an on-site risk manager. All new hires were required to orientate for a full day with the risk manager. My orientation included my becoming familiar with the types of issues I would want to notify the risk manager of, what her duties were, which forms I may need to use such as incident reports, and the protocol regarding incident reports.

There were policy books that explained rules and regulations in her office and at each nurse’s station. I followed her throughout the day as she attended meetings and listened to the concerns of other employees. Having a risk manager in the facility was an advantage and was an interesting learning experience. Two Significant Risk Management Issues Two significant risk management issues occurred when a registered nurse on a skilled unit administered IV Vancomycin.
Shortly after the infusion began the resident complained to her certified nursing assistant (CNA) of a burning pain in her arm. The CNA reported the complaint to the nurse who told the CNA to explain (to the resident) that the medicine is expected to burn but that she would be there to see the resident shortly. The CNA later said she was delayed approximately 20 minutes before returning to the resident whom by that time was in tears. The CNA used the call light for assistance and an LPN responded. This nurse immediately turned off the infusion pump.
Her assessment found the resident to have a pain score of 10. Her IV site was red, hard to the touch, and painful. The nurse said she could palpate the vein and it felt cord like. The nurse elevated the resident’s arm on pillows, applied a warm compress, and called the physician. The second risk management issue occurred when the RN that infused the Vancomycin did not properly document the incident. There was a series of events that should have occurred when the nurse became aware of the order to give the medication.
Steps Taken To Address the Issues. Steps were taken by the risk manager, director of nurses, and other managers to ensure such an incident would not happen again. During the time this event took place the risk manager and the Director of Nursing had initiated talks with corporate executives about finding constructive non-punitive ways of correcting nursing errors. Previously, when nurses made mistakes they engaged in deception out of fear of being punished. Leaders realized hiding errors could potentially harm residents and removed the opportunity for nurses to learn from their experiences.
This nurse would be one of the first to be in a pilot program that required nurses that had made a nursing error to be trained in policies and procedures regarding their situation. The nurse received training in IV placement, infusion, and documentation. She was also taught the signs and symptoms of complications and steps to manage infiltration and extravasation. She was not able to put in an IV or infuse IV medications until she satisfactorily demonstrated her competency (Hadaway, 2007). Our risk manager could not emphasize the importance of accurate and legible documentation enough.
In the instance of this nurse, the appropriate documentation would have included describing the initial placement of the IV cannula, the gauge, site characteristics, and the resident’s condition and tolerance of the procedure. Documentation should have continued regarding the resident’s condition, nursing interventions, evaluations and resident outcomes. An incident report should have been initiated, not mentioned in the chart, but noted on the 24 Hour Report, a nursing communication tool for all shifts. The most appropriate remedy for these two problems was education and re-training.
Non-punitive error resolution was one of the most productive ideas nursing management had developed at SJSC. This approach increased morale, raised the awareness of nurses and managers, and increased the confidence and skills of most nurses that participated. Unfortunately, as managers changed and the risk management department relocated, the concept was discussed now and again but would not be implemented in their long term care facilities. Adoption of Valid Methods The most valid method in my opinion would be the Just Culture model that has been adopted by several hospitals across the country.
The Institute of Medicine’s “To Err is Human” made a major impact on the thinking of many influential healthcare professionals and helped them to reconsider the punitive culture that had dominated healthcare for centuries. One of the most prominent hospital systems, such as those hospitals under the United States Department of Veterans Affairs, has recognized the wisdom of committing to the Just Culture model in the development of their health care workers (Barger, Marella, & Charney, 2011).
Comparison of Results. The SJSC risk manager may never have used the phrase “Just Culture” when relating to staff nurses but she did use the principles. Perhaps had the management of Seattle Children’s Hospital embodied the concepts of a just culture a nurse’s life could have been spared. On September 14, 2010, Kimberly Hiatt, a registered nurse on the pediatric ICU, administered a fatal dose of calcium chloride to a critically ill eight month-old infant. Everyone in Kim’s circle knew that she was absolutely devastated.
Her family, friends, and co-workers all attested to the unraveling of her life during the months after the incident. During a time when she surely could have used the support of her employers they decided to cut their ties to a nurse whom had gone from being an asset to a liability almost overnight. Kim had been a nurse for 25 years, all of them at Seattle’s Children’s Hospital. She had been one of their most dedicated, compassionate, and knowledgeable nurses according to her co-workers. Kim had immediately reported the incident.
She explained in writing that she had been talking to someone while drawing up the medication and had miscalculated the dose. This was her first medication error in 25 years of working there. She went on to say that she was “simply sick about it”. Kim was suspended immediately after the baby died and was terminated shortly afterward. Six months following the incident Kim committed suicide. There were two tragedies in this scenario. The outcome for Kim could have possibly been different had some of the stakeholders involved in the case reconsidered their positions.
After Kim’s death the hospital decided to adopt the Just Culture model and now chooses to use errors to examine and correct systemic problems rather than focusing on penalizing an individual. I would like to have seen the hospital take this stance before Kim gave up but I appreciate the fact that she and the baby’s death were not in vain (Aleccia, 2011). Conclusion Until I prepared the research for this paper I thought of risk management as a legal watch dog for an organization’s financial assets and reputation.
I had never met a risk manager prior to my job and I was impressed with the dedication our risk manager devoted to our staff, especially the nurses. I realize now that our risk manager was focused on changing the staff’s perception of our ownership for managing the risks our facility faced. We learned from her the importance of each employee being aware of the risks around us and reporting the hazards and problems we saw. We learned to be accountable for making safe choices, ethical decisions and following procedures to keep our residents and each other safe.

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