Risk Management

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Risk Management
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• It is a mark of the educated man and a proof of
  his culture that in all matters he looks for only
  as much detail as the nature of the problem
  permits or its solution requires.
• Aristotle

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The components of quality

• Attitude
• Audit
• Risk Management
• Patient focus
• Life-time learning
• Systematic care
• Valuing practitioners
• Supporting innovation

From the NHS Plan
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Why do things go wrong?
Organisational No strategies Poor management Poor
communication Sparse infrastructure

• Cultural
• Weak leadership
• Education and research not valued
• Cliques and factions

Individual Poor motivation Poor teamworking Poor
attitude Lack of skills
External Defensive Fortress mentality Little
collaboration
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System failures

• Arrogance
• Denial
• Blame
• Shooting the messenger.
• Averting the gaze
• Failure to think systems
• Passive learning

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What is risk?

• Risk is the probability that a situation will
  produce harm under specific conditions - the
  probability that something you do not want to
  happen will happen.
• It is measured in terms of likelihood and
  consequences and modified by the frequency of the
  activity that may lead to risk.

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Risk Management

• Focus on the system rather than the individual
  incident
• It is anticipatory not reactive in emphasis
• Significant event audit and adverse incident
  reporting therefore supports risk management by
  monitoring it
• It is a relatively new concept in primary care
• No systematic reviews or evidence base for
  primary care

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Why do Risk Management?

• To enhance patient safety
• Clinical governance
• Organisations with a memory
• Complaints procedures
• Personal/practice development plans
• Appraisal
• Re-validation requirement?

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Why do Risk Management?

• A number of widely publicised high profile cases
• 850,000 adverse incidents per year 1/3 leading
  to disability or death1
• 50 avoidable according to US studies
• 2 billion/year in additional in-patient stays
• 400 million in compensation
• 1 Vincent C, BMA conference, March 2000

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Principal areas of concern

• Diagnosis
• Prescribing
• Communications
• Organisational change

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Diagnosis

• In one study
• 28 of reported errors in this category
• 50 of these had potential for serious harm
• Asthma, cancer, dermatology, substance abuse,
  depression
• Tension between under-referral and over-referral
• Uncertainty of diagnosis in primary care
• No proven benefit from decision support and
  guidelines

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Prescribing

• 3-5 problem rate, one third potentially serious
• Over a 6 year period 25 settled MDU claims were
  in this area
• Computer assisted prescribing
• NSFs and polypharmacy

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Communication

• Hierarchical structures
• Informal communications
• Transcription errors
• Cross boundary transitions
• Non-availability of information

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Organisational

• Examples from industry
• Visible organisational structures and processes
• Strategies, goals and philosophies
• Beliefs perceptions and feelings
• Primary care?
• Leadership
• SEA
• Philosophy
• Teamwork
• Sharing best practice

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Relationship to critical event audit
Significant event audit
Risk Management
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What informs the risk management process?
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Organisations with a memory

• Unified mechanism for reporting and analysis
• Near miss concept
• A more open culture to discuss service failures
• Mechanism for ensuring change happens as a result
  of lessons learned
• Systems approach in preventing, analysing and
  learning from errors

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National Patient Safety Agency
Prof Rory Shaw, Chair NPSA
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NPSA definition

• Any event or circumstance that could have lead
  to un-intended or unexpected harm, loss or damage

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Possible reportable incidents

• Unexpected death while under direct care
• Death on premises
• Suicide/homicide by patient under treatment for
  mental disorder
• Potentially lethal or serious health care
  associated infection
• Proven rape
• Wrong patient/body part
• Retained devices
• Haemolytic transfusion reaction
• Child abduction or incorrect discharge
• Incorrect radiation exposure

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Benefits

• better outcomes and patient satisfaction
  (improved quality of service)
• ability to learn from mistakes
• reduced costs of litigation and compensation
• better public image
• better allocation of resources
• more informed decision-making
• greater compliance with legislation
• greater transparency and accessibility to
  external review

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Examples
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Clinical

• Failure to adequately examine a patient or
  appreciate the severity of an illness
• Failure to fully document or send samples to the
  lab
• Prescribing errors e.g. drug allergy
• Inadequate records
• Inexperienced clinical staff or staff asked to
  exceed their competencies
• Inadequate/unavailable medical records
• Failure to provide informed consent

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Non-clinical

• Maintenance of equipment/ buildings
• The hostile patient
• Waste management
• Infection control
• Fire safety
• Employers liability
• Message handling
• Staff turn-over
• Security of information

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Key requirements

• Leadership and commitment of an identified
  individual
• Policy and strategy
• Planning and organisation
• Resourcing
• Process - incident reporting and investigation or
  complaints handling
• Claims management
• Measurement evaluation and improvement
• Audit

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What next?
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The risk management process

• Tea and a break prevents dehydration and boredom!
• Tools to assist risk management
• Some worked examples.

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Risk Assessment for Respite Care
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