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HLT 308V Week # 1 Assignment: Risk Management Analysis; Part No. I
Risk Management Plan and Audience
High alert medications and high risk processes that focus on the use of anticoagulants is
the specific plan that was chosen for this report. The specific audience for this report is nursing
staff, pharmacist and providers who will be administering or preparing high risk medications,
specifically anticoagulants. This topic was chosen because of the high likelihood of hard that can
be done when a patient is prescribed anticoagulant therapy, and the high rate of errors present in
anticoagulant therapy.
Firstly, a high alert medication are medications that can cause significant harm if subject
to a medication error. The frequency that many of these medications are used contributes to the
lack of proper safeguard use in hospitals which could contribute to the error rate. (Lu, Yu, Chen,
Wang, Wu, & Tang, 2013). Although increased rate of errors is not necessarily a criterion for
being classified as “high-alert” status, anticoagulants categories have been associated with more
medication errors than any other medications, according to the Institute for Safe Medication
Practices(ISMP) (2014). Increased attention has been a focus of hospitals and accrediting bodies
since 1999, when the US Institute of Medicine released the book To Err is Human- Building a
Safer Health System (Lu et. al, 2013).
Recommended Process vs. Facility
There are many regulatory bodies that have taken notice High-Alert Medications, also
known as HAM’s, and have specific recommendations for the processes involved in their
administration. To start, Federal and State laws are the major contributing bodies; however, they
also highly rely on other organizations to help identify areas that could help improve the
medication administration process such as the National Coordinating Council for Medication
, Risk Management Program Analysis Part One 2
Error Reporting and Prevention, National Institute of Health, Institute for Healthcare
Improvement, Institute for Safe Medication Practices, and The Joint Commission Hospital
Accreditation (CMS, 2011). In fact, even the Center for Disease Control publishes guidelines for
safe-practice and administration of medications.
The standard information include in drug orders is recommended to include the name,
age, weight, date and time of the order, drug name, dose, frequency, route, concentration, quality
or duration, any specific instructions, and the name of the prescriber. There are also clear
guidelines that ensure that personnel that are administering medications should be trained on safe
handling, and preparation of the medication.
Many facilities have standing policies in place for the use of anticoagulants. These
standing orders allow for nursing staff, or authorized users, to initiate a medication
administration process that fits specific guidelines. These orders still have be authenticated by a
physician, although they do not need specific orders as long as the criteria is met within the
policy, and the policy as well-defined guidelines (CMS, 2011).
The facility being used to compare processes with is Kaiser Medical Center- San
Leandro. This facility has one policy that outline protocols pertaining to the administration of
anticoagulants. Within this policy there are key points that help protect the patient, and the staff
member from making mistakes when dealing with high-risk anticoagulants.
This policy outlines the use of preformatted order sets for anticoagulation therapy. These
preformatted order sets help cut down on errors related to the complexity of dosing that is
common in anticoagulants. These order sets were developed in collaboration of the pharmacy
department, which verify the order in real time as well. This policy also outlines conditions that
can impact standard anticoagulant dosing such as: coagulant or platelet defect, ulcerative
HLT 308V Week # 1 Assignment: Risk Management Analysis; Part No. I
Risk Management Plan and Audience
High alert medications and high risk processes that focus on the use of anticoagulants is
the specific plan that was chosen for this report. The specific audience for this report is nursing
staff, pharmacist and providers who will be administering or preparing high risk medications,
specifically anticoagulants. This topic was chosen because of the high likelihood of hard that can
be done when a patient is prescribed anticoagulant therapy, and the high rate of errors present in
anticoagulant therapy.
Firstly, a high alert medication are medications that can cause significant harm if subject
to a medication error. The frequency that many of these medications are used contributes to the
lack of proper safeguard use in hospitals which could contribute to the error rate. (Lu, Yu, Chen,
Wang, Wu, & Tang, 2013). Although increased rate of errors is not necessarily a criterion for
being classified as “high-alert” status, anticoagulants categories have been associated with more
medication errors than any other medications, according to the Institute for Safe Medication
Practices(ISMP) (2014). Increased attention has been a focus of hospitals and accrediting bodies
since 1999, when the US Institute of Medicine released the book To Err is Human- Building a
Safer Health System (Lu et. al, 2013).
Recommended Process vs. Facility
There are many regulatory bodies that have taken notice High-Alert Medications, also
known as HAM’s, and have specific recommendations for the processes involved in their
administration. To start, Federal and State laws are the major contributing bodies; however, they
also highly rely on other organizations to help identify areas that could help improve the
medication administration process such as the National Coordinating Council for Medication
, Risk Management Program Analysis Part One 2
Error Reporting and Prevention, National Institute of Health, Institute for Healthcare
Improvement, Institute for Safe Medication Practices, and The Joint Commission Hospital
Accreditation (CMS, 2011). In fact, even the Center for Disease Control publishes guidelines for
safe-practice and administration of medications.
The standard information include in drug orders is recommended to include the name,
age, weight, date and time of the order, drug name, dose, frequency, route, concentration, quality
or duration, any specific instructions, and the name of the prescriber. There are also clear
guidelines that ensure that personnel that are administering medications should be trained on safe
handling, and preparation of the medication.
Many facilities have standing policies in place for the use of anticoagulants. These
standing orders allow for nursing staff, or authorized users, to initiate a medication
administration process that fits specific guidelines. These orders still have be authenticated by a
physician, although they do not need specific orders as long as the criteria is met within the
policy, and the policy as well-defined guidelines (CMS, 2011).
The facility being used to compare processes with is Kaiser Medical Center- San
Leandro. This facility has one policy that outline protocols pertaining to the administration of
anticoagulants. Within this policy there are key points that help protect the patient, and the staff
member from making mistakes when dealing with high-risk anticoagulants.
This policy outlines the use of preformatted order sets for anticoagulation therapy. These
preformatted order sets help cut down on errors related to the complexity of dosing that is
common in anticoagulants. These order sets were developed in collaboration of the pharmacy
department, which verify the order in real time as well. This policy also outlines conditions that
can impact standard anticoagulant dosing such as: coagulant or platelet defect, ulcerative
