“Risk management is notprimarily about avoiding ormitigating claims; rather, it isa tool for improving thequality of care.”
“Risk management is actually thebusiness of all stakeholders inthe organisation, doctors,nurses, allied health staff, nonclinical personnel.”
What is clinical risk management? Clinical risk management (CRM) is an approach to improving the quality and safe delivery of health care by: I. placing special emphasis on identifying circumstances that put patients at risk of harm II. acting to prevent or control those risks.
Basic questions addressed by risk management: What could go wrong? Risk identification What are the chances of Risk analysis and it going wrong and what evaluation would be the impact? What can we do to Risk treatment. The cost minimise the chance of of prevention is this happening or to compared with the cost mitigate damage when it of getting it wrong has gone wrong? What can we learn from Risk control; sharing and things that have gone learning wrong?
Series of steps in CRM process
What are my risk management responsibilities?General staff’s responsibilities: 1. Reporting incidents 2. Identifying and assessing risks 3. Providing additional information on a risk if requested 4. Practicing risk management in day-to- day operations within their areas
What are my risk management responsibilities?Manager’s responsibilities: Participating in the review and update of operational risk profiles; Ensuring that risks are identified, managed and monitored on an ongoing basis within their areas. Overseeing the coherent and consistent use of risk management techniques by those staff reporting to them; Practicing risk management in operational decision making and in day-to-day operations within their areas; Having risk management as a regular agenda item for team meetings; and Ensuring that risks are accurately and timely recorded in order to facilitate risk management reporting.
What is an incident? An incident is an event which could have or did lead to unintended or unnecessary harm to a person and/or a complaint, loss or damage. Incidents include near misses, adverse events, sentinel events and unsafe acts. 1. The wrong dosage or route of medication administered to a patient 2. A dosage of medication not given when prescribed to be given 3. The wrong treatment / procedure 4. A staff member injured in the course of their duties 5. Injury to a visitor / patient e.g. fall on a wet floor in the hallway
How do I report an incident?1. The incident should be entered into the incident reporting system as soon as practical, to ensure accurate recording of detail.2. The staff member reporting the incident should also inform their manager of the incident.
What happens then?1. The incident report will be forwarded via the system to your nominated manager and the appropriate quality manager.2. If there are risk control activities that can be conducted at a local level then these should be commenced and the matter should be discussed at your team meeting.3. Incidents or hazards that have a major or catastrophic potential or actual outcome will be formally investigated.
Inappropriate use of incident reporting1. To performance manage a staff member2. To allocate blame for an event3. For personal grievances4. For harassment or discrimination
What is a Sentinel Event? A sentinel event is a subset of adverse events specified by the MOH These events rarely occur but are more serious and are therefore reported to MOH and investigated immediately using a Root Cause Analysis process They commonly reflect hospital systems and process deficiencies and result in unnecessary outcomes for patients. For O&G: Maternal death from heart diseases and recurrent eclampsia
What is "Root Cause Analysis"? Root Cause Analysis (RCA) is a method of investigation. The purpose is to identify organisational deficiencies that may not be immediately apparent and which may have contributed to the cause of the event. A RCA report also includes risk reduction strategies to reduce the chance of a similar event occurring again.
What do I tell the patient and family? ‘Open disclosure refers to the process of open communication with patients and their families following an adverse event A senior member of the managing team should be involved: 1. Ward specialist/Specialist on-call 2. CRM matron 3. HOD if situation warrants it Several meetings/counseling may be necessary Offer support and assistance to patient and family
Safety & Security:SAFETY: Think & practice risk management in operational decision making and in day-to-day operations in all areas Adhere to SOP and guidelines in the delivery of careSECURITY: Adhere to all existing security procedures to ensure the safety of our patients and babies
The String Theory: We are all interconnected Effective communication reduces risks Develop relationships Teamwork makes us resilient We are as strong as the weakest link If one fails…the team fails..and the patient suffers!