The way the risk manager could prevent these types of events from occurring in the future would be to establish and maintain a functional pediatric formulary system with policies for the evaluation, selection and therapeutic use of drugs. To avoid timing errors in medication administration, standardize how days are counted across all protocols by deciding on a protocol start date. Limit the number of concentrations and dosages of high-risk medications to the minimum necessary to provide safe care. Assign a physician specializing in pediatrics to any committee responsible for overseeing medication management. Develop pre-printed medication order forms and clinical pathways or protocols to reflect a standardized approach to care. Includes reminders and parameter monitoring information. On inpatient drug orders and outpatient prescriptions, require prescribers to include the calculated dose and dosage determination, such as dose per weight (e.g., milligrams per kilogram) or body surface area, to facilitate independent double-checking of the calculation from part of a pharmacist, nurse or both. Finally, have a pharmacist with pediatric experience available or available at all times (Prevention of Pediatric Medication Errors, n.d.). To prevent the event from happening again, applying all of the above tips would significantly reduce the chances of the event happening again. Above all education was extremely necessary in the unit. Organize a two-week training seminar at staggered times, allowing all staff involved to inform themselves about the pitfalls that have occurred. A risk manager should also regularly organize surprise inspections of the unit. Below is a checklist of what should happen…half of the document…are believed to be the most common type of medical error and are a significant cause of preventable adverse events (Prevention of Pediatric Medication Errors, n.d. ). Risk managers play a huge role in preventing and controlling risks that arise in the healthcare industry. Performing routine mock safety inspections in all hospital units can bring to life the risks that occur in the ever-changing atmosphere of hospitals. Sentinel events can seem like a detrimental setback to a healthcare organization. However, by regularly reevaluating current policies and procedures it is possible to uncover unsafe practices in place. Everyone who works in the healthcare industry has the same goal: to keep patients as safe as possible and provide the best care. Risk managers maintain the same set of standards even if their job description is different from that of a clinical professional.