THE BASICS OF RISK MANAGEMENT

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THE BASICS OF RISK MANAGEMENT
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Housekeeping
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STRUCTURE FOR THE DAY

• Risk Management recap
• Risk Management under the microscope
• Tools and Techniques
• Patient Safety Case Study

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Risk Management recap
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Risk is .

• The management of UNCERTAINTY to increase the
  probability
• of success and reduce the probability of
  failure.
• Risk is inherent to any activity, has the
  potential to affect your success, and can be both
  negative and positive.
• With risk comes opportunities for growth and
  development.
• It can be shaped but not totally
  eliminated!

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What is Risk Management in NHS Scotland

• Risk management is the systematic identification,
  assessment and reduction of risks to patients,
  staff and the organisation (NHS HIS)
• Risk management proactively reduces identified
  risk to an acceptable level by creating a culture
  founded on assessment and prevention rather than
  reaction and remedy. (NHS HIS)
• The aim of risk management is to create a culture
  in which NES staff and stakeholders are aware of
  risk and its potential impact, and in which they
  are aware of their responsibilities in relation
  to the management of risk, thereby promoting an
  open and responsive approach to risk management
  which actively involves all elements of NES.
• (NHS Education for Scotland)

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We all naturally manage risk every day..
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14 storey building
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Benefits of Risk Management

• Supports strategic and business planning
• Promotes continuous improvement and
  identification of new opportunities
• Encourages innovation and creativity
• Engenders a proactive outlook
• Ensures robust contingency planning
• Improves our ability to meet objectives and
  achieve opportunities
• Reduces shocks and unwelcome surprises
• Advocates transparency
• Furthers compliance with governance agenda
• Stimulates regular review and monitoring of
  business processes
• Enforces ownership
• Provides for effective use and prioritisation of
  resources
• Reassures staff, stakeholders and governing
  bodies
• Enhances communications internally and with
  external stakeholders
• More informed decision-making.

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Risk Management under the microscope
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Identifying and Managing a Risk
Monitor and review
Identify the risk
Plan / implement additional actions
Evaluate the risk
Manage the Risk
Risk response (ownership and priority)
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How to identify a Risk - some questions to ask

• Risk Management relates to the identification of
  uncertainties and what actions could be taken to
  mitigate against them, or even encourage them.
• Has this event happened before in our
  organisation (or a team) or in another similar
  organisation? Could it happen again?
• What are the key dependencies / core processes
  / routine operations of our organisation (or a
  team)? Are there any possible things that could
  affect their continuity?
• What are our main objectives? What might
  prevent them from being achieved?
• Are there any new activities / developments /
  products / improvements that could impact
  existing functionality or bring in new risks for
  us (or a team)? What can be done in mitigation?
• What opportunities are there that we could
  benefit from?
• Does the event relate to our Accountability/Gove
  rnance requirements our Financial position our
  Operations / Service Delivery our Reputation or
  Credibility Health Safety?

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Sources of Risks

• Risks to the project / function / activitys
  existence
• - strategic direction / policy change funding /
  staff withdrawal
• Risks from within the project / function /
  activity
• - overspending over-run poor quality
  end-product
• External Risks (more difficult to predict)
• - customer / stakeholder pressures
  socio-political pressures environmental pressures

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Identifying and Managing a Risk
Monitor and review
Identify the risk
Plan / implement additional actions
Evaluate the risk
Manage the Risk
Risk response (ownership and priority)
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Evaluate the Risk - Risk Decision Path
removes
risk eradicated, however inaction may lead to
other risks
reduces

likelihood of loss
PROACTIVE
risk subcontracted risk
occurrence insured against
controls in place to reduce likelihood of risk
occurring
reduces

impact REACTIVE
actions in place to deal with risk when it occurs
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Identifying and Managing a Risk
Monitor and review
Identify the risk
Plan / implement additional actions
Evaluate the risk
Manage the Risk
Risk response (ownership and priority)
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Prioritising Risks

• In NHS Scotland Risk is measured in terms of its
  impact and likelihood
• Impact - a reflection of the pain or loss or
  discomfort that may be caused by an event
• Likelihood - an indication of how often we can
  expect a particular event to occur
• In NHS Scotland, risk is scored on a 5 x 5 matrix
  and ranges from negligible to catastrophic
• Risk is summarised into Low, Medium (Housekeeping
  or Contingency) and Primary risks.

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NES Scoring Matrix
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Managing a Risk - jargon

• Corporate Governance
• The system by which companies are directed and
  controlled
• Event
• The occurrence of a particular set of
  circumstances
• Mitigation
• The act of making a consequence less severe
• Issues v Risks?
• Risks are things that might happen, issues are
  things that are actually happening
• Controls v Actions?
• Controls are mitigation measures already in
  place, actions are new controls that we are
  currently working on.

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We are all personally responsible for managing
risks
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The Cumulative Act EffectThe SWISS CHEESE of
Risk Management
James Reason 1990
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Reasons for latent failure
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Significant Event Analysis (SEA)

• Carried out in individual cases in which anyone
  in the team thinks there has been a significant
  occurrence (not necessarily involving an
  undesirable outcome for the patient) are analysed
  in a systematic and detailed way to ascertain
  what can be learnt about the overall quality of
  care and to indicate
  changes that might lead to
  future improvements

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Root Cause Analysis (RCA)

• A structured approach to identifying the factors
  that resulted in the nature, the magnitude, the
  location, and the timing of the harmful outcomes
  (consequences) of one or more past events in
  order to identify what behaviours, actions,
  inactions, or conditions need to be changed to
  prevent recurrence of similar harmful outcomes
  and to identify the
  lessons to be learned
  to promote the achievement of
  better consequences.

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Problem Solving - Some tools and techniques

• Bonos Six Thinking Hats
• Brainstorming
• PEST(LE)
• SWOT
• Five Whys / So What
• Ishikawa Fishbone
• Barrier Analysis
• Significant Event Analysis
• Root Cause Analysis

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Barrier Analysis

• Technique used in Root Cause Analysis or
  Significant Event Analysis, and can be used
  reactively to solve problems or proactively to
  evaluate existing barriers.
• The term barrier is used to mean any barrier,
  defence or control that is in place to increase
  the safety of a system.
• Four types of barrier Physical Natural Human
  Actions Administrative
• Identify the process to be reviewed
• Identify all control measures in place
• Ensure you have Physical and Natural barriers
  (failsafe)
• Consider additional control measures that would
  be useful
• Consider the costbenefit of additional measures
• Assign ownership and action new additional
  measures
• Repeat regularly
  (Proactive Barrier Analysis Dineen 2002)

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Inadvertent Harm A Case Study
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Inadvertent Harm

• This is a case study prepared by the National
  Patient Safety Agency in England and is based on
  a real incident.
• In 1968, vincristine was first administered
  intrathecally (ie into the spine) in error to a
  young patient with acute lymphocytic leukaemia.
  She died 3 days later.
• Intrathecal administration of vincristine is a
  rare event but catastrophic for the patient,
  family and clinical team involved. Over 40 years,
  58 cases of intrathecal vincristine errors are
  known to have occurred across the world.

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Timeline - characters
Jazmin Munroe Consultant
Charlotte Green Pharmacist Tech
Mr Shah Pharmacist
Jane Hughes Patient
Duncan Campbell New Specialist Registrar
Liam Short Staff Nurse
Helen Roberts Relief Sister
Abe Kamole Staff Nurse
Fiona Livingstone Specialist Registrar
Joe Robinson Relief Junior Doctor
Ann Lynch Ward Sister
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Inadvertent harm timeline variations

• Before the day
• Patient and Consultant agree to IV and IT
  treatment on same day
• On the day
• Pharmacist issues Vincristine (IV) and
  Methotrexate (IT)
• Ward Sisters in charge unable to handover at
  shift change
• Patient arrives late
• Ward SpR unexpectedly leaves Ward
• Patient taken to dedicated bay and plugs into her
  walkman
• Staff Nurse called away to emergency
• Locum SpR and SHO left alone to administer
  chemotherapy drugs.

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Inadvertent Harm

• Thinking back to your pre course reading
• What prevention barriers were in place?
• Did the barrier work?
• If it failed, why?
• How did the barrier affect the consequence of the
  event?
• What could you do to try to prevent an incident
  of healthcare associated harm occurring in the
  future?
• What lessons could be learned from such an
  incident?

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No Blame

• In NHS, when a serious incident occurs, in order
  to fully learn from the event, a policy of no
  blame is taken (you dont usually come to work
  planning to deliberately harm someone or do a bad
  job!)
• But what could the pharmacy staff in particular
  have done differently?
• Vincristine (IV) and Methotrexate (IT) should not
  have been issued on same day, Pharmacist raises
  concern but is over-ridden
• Pharmacist Technician knows she should not
  dispense the Methotrexate (IT) to someone who is
  not on the register, but is over-ridden
• Pharmacist Technician does not confirm that the
  Vincristine (IV) has been administered before
  dispensing the Methotrexate (IT)
• Pharmacist Technician does not confirm that the
  Methotrexate (IT) will be administered
  immediately to the patient and not stored on the
  ward.

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General Lessons to be learned
CAUSE EFFECT
Lack of proper handover at various points poor communication
No competency test required for administration of drug inadequate and out of date policy
Senior officer completely absent but accountable assumes staff will fulfil wishes without clarifying them
Dr Livingstone leaves unexpectedly / Sister Lynch leaves early / SN Abe called to emergency suitably qualified staff not present when needed
Dr Campbell not on IT register, busy environment leads to lack of concentration hierarchy overrides written policy, Pharmacist Technician should not have dispensed Methotrexate (IT)
Patient taken to IT bay even though no IV drug administered yet over-reliance on policy and procedure
Drug bag checked for patient details but not drug contents half application of policy leads to comfort that the entire policy is being adhered to.
Two chemo drug fridges breach of policy and also not sufficiently labelled for outside people to use properly
Dr Campbell sends Dr Robinson to get the chemo use of jargon which is easily misinterpreted
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Inadvertent Harm an afterthought

• Route delivery errors account for approximately
  5 of medication errors. (Bates DW, Boyle DL, et
  al Relationship between medication errors and
  adverse drug events. J Gen Intern Med
  199510199205.)
• Such incidents attract serious incident enquiries
  and proposals have been made involving the
  physical redesign of delivery systems such that
  it is impossible to deliver drugs by the wrong
  route.
• To date, an international agreement on such
  standardisation is yet to be
  reached.

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Summary - We are all risk managers

• Everyone in the organisation is involved in the
  management of risk
• Risk is a proactive tool in supporting and
  informing decision-making
• Any time is a good time to review the risks in
  your work area and plan mitigations to prevent
  them / cope when they occur

• If you are commencing a new project or large
  piece of work, your planning would be aided by
  considering the risks and introducing controls to
  mitigate against them happening or take steps to
  reduce their impact if they are not preventable.

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Today we have covered

• Risk Management recap
• Risk Management under the microscope
• Tools and Techniques
• Case Study

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Thank you for participating

• Any questions?