Risk management


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Dear Colleagues,
I would like to this topic with you.
I have presented in one of the Khartoum conferences few years ago.
I felt it might be of value to some of you mainly those taking their second part exams or those providing safe women health services business.

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  • The nuclear and aircraft industries were the first to develop formal methods for risk management in the 1950’s. Following the Flixborough disaster the chemical industry adopted these formal methods and developed further techniques (for example, HAZOP). The oil and gas industry began to take risk management seriously after Piper Alpha, and the Transport sector following the Clapham Junction crash and Kings Cross fire. The push for the Finance Sector came from Barings Bank. It is interesting to note that the Paddington crashes occurred after they had apparently put all of the necessary safety systems in place. Reviews of those crashes agree that all the right systems were in place, but that the culture in the organisations was wrong.
  • In 1991 a famous study was conducted in the US (known as the “Harvard Study”) where a large number of patient records, and corresponding outcomes, were reviewed retrospectively. The reviewers were asked to identify where there was clear evidence that patients had been harmed by their care while in hospital and where this had led to significant detriment to the outcome. The results were shocking, and led to further studies and then action supported directly by the then US President. These included the establishment of national systems (e.g. Sentinel Event Reporting) to reduce the levels of such occurrences. The US study was repeated in the UK and the levels of medical error were, unsurprisingly, found to be similar. A further study in Australia has found similar evidence. The Australian studies were undertaken in 1995 and 1999 and showed a much higher rate – 16.6%. The UK study was in 2000 and showed a 10.8% rate (comparable with the 4% and 16.6% and thus coming in about the middle). A 2000 study in New Zealand came out at 10.7% No such study has yet been conducted in Ireland but it would be remarkable if the levels of error here were much better then those in the U.S., Australia and the UK. What was regarded as one of the most shocking statistics in all of these studies was the number of avoidable deaths that occur. In the UK study it was estimated nationally to be 40,000 each year making it one of the most common causes of death! It should be noted that the researchers are now extremely wary of extrapolation, giving various reasons why you can’t extrapolate. Medical staff in particular may ask questions about the research and the definitions etc. However, this is irrelevant as the extrapolations are now widely reported (including in the press) and the health service has a job on its hands both internally in terms of reducing error and externally in terms of PR!!
  • Risk management

    1. 1. Risk Management Awareness Raising Dr.Ahmed Eltigani Elmahdi Hussain Consultant Obstetrician&Gynaecologist Cavan General Hospital, IRELAND
    2. 2. Risk Management – who does it? <ul><li>Nuclear Industry </li></ul><ul><li>Aircraft Industry </li></ul><ul><li>Chemical Industry </li></ul><ul><li>Oil and Gas Industry </li></ul><ul><li>Transport Sector </li></ul><ul><li>Finance Sector </li></ul>
    3. 3. Why do these industries prioritise Risk Management? <ul><li>… because they are all high risk industries and any breach of safety has far reaching consequences in terms of: </li></ul><ul><ul><li>Their employees </li></ul></ul><ul><ul><li>The general public </li></ul></ul><ul><ul><li>The environment </li></ul></ul><ul><ul><li>Their reputation </li></ul></ul><ul><ul><li>Their survival and profits </li></ul></ul>
    4. 4. Risk Managent – Definitions …The culture, processes and structures that are directed towards the effective management of potential opportunities and adverse events Source: AS/NZS 4360 :1999 R M Standard …The process wherebye an organisation anticipates the potential for injuries or losses and acts to avoid those injuries before and/or to ameliorate them after they occur Source: R M in Health Care – Dr. G. Roberts
    5. 5. Risk Management - Process …The systemic appllication of management policies, procedures and practices to the task of establishing the context, identifying, analysing, evaluating, treating, monitoring and communicating risk Source: AS/NZS 4360 : 1999 R M tandard
    6. 6. Is there any evidence that we should do it in Healthcare? <ul><ul><li>Beverley Allitt </li></ul></ul><ul><ul><li>Bristol Inquiry </li></ul></ul><ul><ul><li>Dr.Shipman </li></ul></ul><ul><ul><li>Blood Transfusion Services Board </li></ul></ul><ul><ul><li>Organ Retention </li></ul></ul><ul><ul><li>McColgan Child Abuse Inquiry </li></ul></ul><ul><ul><li>Dr. Neary </li></ul></ul>
    7. 7. BRISTOL, ENGLAND <ul><li>In the period from 1991 to 1995 between 30 and 35 children under 1 died after open-heart heart surgery in the Bristol Royal Infirmary </li></ul>
    8. 8. ENGLAND <ul><li>Dr Shipman Family GP had become the focus of Europe's biggest ever murder investigation </li></ul><ul><li>Convicted of 15 murders, suspected of killing more than 297 patients over 24 years. </li></ul>
    9. 9. Health Care is a risky business – for patients <ul><ul><li>Harvard Medical Practice Study, 1991 </li></ul></ul><ul><ul><ul><li>3.70% of hospital admissions lead to “adverse events” </li></ul></ul></ul><ul><ul><ul><li>1.85% of hospital admissions lead to avoidable “adverse events” </li></ul></ul></ul><ul><ul><ul><li>0.50% of hospital admissions lead to “adverse events” resulting in death </li></ul></ul></ul><ul><ul><ul><li>corresponds to 120,000 avoidable deaths p.a. in USA </li></ul></ul></ul><ul><ul><ul><li>(corresponds to approx. 170,000 avoidable deaths p.a. in Europe) </li></ul></ul></ul><ul><ul><li>Quality in Australian Healthcare Study, 1995 </li></ul></ul><ul><ul><ul><li>“ adverse event” rates of 14-16% </li></ul></ul></ul><ul><ul><ul><li>98,000 avoidable deaths p.a. </li></ul></ul></ul><ul><ul><li>University College London, 1999 </li></ul></ul><ul><ul><ul><li>UK 8-10% </li></ul></ul></ul><ul><ul><ul><li>Medical error kills >40,000 p.a. in the UK and is the third most likely cause of death after cancer and heart disease (Vincent et al) </li></ul></ul></ul>
    10. 10. <ul><ul><li>Vincent et al, 2001 </li></ul></ul><ul><ul><ul><li>Retrospective review of 1.014 records in London. </li></ul></ul></ul><ul><ul><ul><li>10.8% had an adverse effect (half preventable) </li></ul></ul></ul><ul><ul><li>Building a Safer NHS, 2001 </li></ul></ul><ul><ul><ul><li>Study of 6,500 cases of adverse events </li></ul></ul></ul><ul><ul><ul><li>87 deaths </li></ul></ul></ul><ul><ul><ul><li>345 serious injuries. </li></ul></ul></ul><ul><ul><ul><li>Included hospital acquired infections </li></ul></ul></ul>Health Care is a Risky Business – for Patients
    11. 11. How often do errors in care occur? <ul><li>United Kingdom: 10-11% </li></ul><ul><li>New Zealand: 10% </li></ul><ul><li>Denmark: 11% </li></ul><ul><li>Australia (latest): 11% </li></ul>Around one in ten hospitalised patients suffer an adverse event
    12. 12. Prescribing Errors <ul><li>In 2000, an estimated 1,200 people in England & Wales died as a direct result of medication prescribed </li></ul><ul><li>(Audit Commission 2001 ) </li></ul><ul><li>Out of 193 claims, 19.3% were caused by prescribing errors. </li></ul><ul><li>36 INCORRECT MEDICATION </li></ul><ul><li>24 CAUSED BY WRONG DOSE </li></ul><ul><li>(MPS 2000) </li></ul>
    13. 13. Why is Risk Management an issue in Healthcare? <ul><li>US - Medication errors cost 5-10% of healthcare budgets to remedy </li></ul><ul><li>NHS - Excess bed occupancy due to medical error costs £750m pa </li></ul><ul><li>NHS - Hospital acquired infections costs £1b pa </li></ul><ul><li>NHS - Excess nursing absenteeism costs £200 - £400m pa </li></ul><ul><li>NHS - 500k accidents to visitors and staff in hospitals costs £154m pa </li></ul><ul><li>US - For every $1 cost of iatrogenic disease in the acute sector $1 is incurred in the community </li></ul><ul><li>1 acute patient in 1000 will die of a hospital acquired infection ie 15% - 30% of which are preventable </li></ul><ul><li>1 acute patient in 100 will die of a pulmonary embolus ie 50% - 100% of which are preventable </li></ul>
    14. 14. Why is Risk Management an issue in Healthcare? cont… <ul><li>Health Care is a Risky Business – </li></ul><ul><li>for staff </li></ul><ul><li>UK Health and Safety Commission, 1999: </li></ul><ul><ul><li>“ Average days lost per worker per annum due to work related illness ” </li></ul></ul><ul><ul><li>Armed Forces 0.30 </li></ul></ul><ul><ul><li>Construction 2.18 </li></ul></ul><ul><ul><li>Coal Mining 2.35 </li></ul></ul><ul><ul><li>Nursing 2.74 </li></ul></ul><ul><ul><li>Average for all occupations 0.71 </li></ul></ul>
    15. 15. Why is Risk Management an issue in Healthcare? cont… <ul><li>Health Care is a Risky Business - for staff </li></ul><ul><ul><li>Sickness absence in the UK NHS costs £700m p.a. Sickness absence rates of 5% compare to a national average of 3.7% representing £200m p.a. excess sickness absence for healthcare workers. (Williams, Mitchie, Pattani, 1998) </li></ul></ul><ul><li>And it’s costly……wherever you work……. </li></ul><ul><ul><li>There are 9000 to 9500 work related compensation claims in the Irish courts each year (Byrne, 2001) </li></ul></ul>
    16. 16. Why is Risk Management an issue in Healthcare? cont… <ul><li>Healthcare is a stressful business…. </li></ul><ul><ul><li>46% of nurses feel “unsafe” at work and 17% perceive excess stress and insufficient support </li></ul></ul><ul><ul><li>(Zurich Municipal/Glasgow Caledonian University, 1999) </li></ul></ul><ul><ul><li>30% of medical students suffer stress related disorders and 10% suffer mental illness (Wrate, 1999) </li></ul></ul><ul><ul><li>66% of doctors use alcohol to relieve stress, 40% feel negative affect toward patients (Firth-Cozens, 1999) </li></ul></ul><ul><ul><li>public scrutiny and expectations of healthcare workers increases vulnerability to stress (James, 1999) </li></ul></ul>
    17. 17. Clinical care The environment of care Financial resources CLINICAL GOVERNANCE ORGANISATIONAL CONTROLS FINANCIAL CONTROLS Health & Safety Human Resources Integrated Care Due Diligence Risk Strategy Quality Reviews Risk Reviews Clinical Audit Practice Developments Claims Management Education & training Performance Management Re-engineering of Systems Service Continuity Planning Healthcare Risk Management
    18. 18. The keys to making Risk Management work <ul><li>Context </li></ul><ul><li>Culture </li></ul><ul><li>Risk Management Systems </li></ul>
    19. 19. Establish Context Identify Risks Analyse Risks Treat Risks MON I TOR Evaluate Risks The Context – The Risk Management Process AS/NZS 4360:1999 Risk Management Standard COMMUNI CATE
    20. 20. Stop it Accident Incident Investigation Task Person Discipline them Past Approach: Person centred investigations Situation ??????
    21. 21. Why a systems approach? <ul><li>Person approach </li></ul><ul><li>Who can we blame? </li></ul><ul><li>Doesn’t get to the bottom of the problem </li></ul><ul><li>Discourages reporting </li></ul><ul><li>System Approach </li></ul><ul><li>What can we learn? </li></ul><ul><li>Looks at individuals as just one component of event </li></ul><ul><li>Analyses all factors & how they interact </li></ul><ul><li>Individuals are fallable </li></ul><ul><li>Errors are inevitable </li></ul><ul><li>Not who made the error but why did the defense systems fail? </li></ul>
    22. 22. Defence Barriers J. Reason 1994 Case Analysis Using Reason’s Statistical failures in defences Organisational Accident Causation Model
    23. 23. J. Reason 1994 Case Analysis Using Reason’s Organisational Accident Causation Model Statistical failures in defences Situation Task Errors Violations Corporate Culture Management decisions and organisational processes Local climate Error- producing conditions Violation- producing conditions Defence Barriers Latent failures in defences
    24. 24. Focus on process not individual “ People and perfect processes make a quality health service. Poor quality results from a badly designed and operated process, not from lazy or incompetent health care workers” Source: John Øvretviet, 1992 Health Service Quality
    25. 25. And Risk Management involves….. (AS/NZS 4360 and HSA “Workplace Health & Safety Management” ) IMPLEMENT MONITOR & REVIEW PLAN POLICY
    26. 26. And Risk Management involves….. (AS/NZS 4360, Chapter 2) IMPLEMENT MONITOR & REVIEW PLAN POLICY Objectives “ Criteria” Safety Statement RM Policy
    27. 27. <ul><li>Objectives of Risk Management </li></ul><ul><li>Minimise risks to quality of service and patient outcomes </li></ul><ul><li>Ensure provision of a safe and effective service </li></ul><ul><li>Confirm that service outcomes reflect planned intentions </li></ul><ul><li>Ensure that services are provided in an equitable and responsive fashion </li></ul><ul><li>Manage risk in partnership with patients, staff, the community and other providers </li></ul><ul><li>Provide a safe and secure environment for staff and patients </li></ul><ul><li>Ensure effective and efficient use of resources </li></ul><ul><li>Seek to learn from mistakes and not to blame </li></ul>
    28. 28. Some Important Definitions Near Misses <ul><li>Actual occurrences which might have resulted in harm </li></ul>Incidents <ul><li>Actual occurrences of harm </li></ul>Risk <ul><li>The likelihood that those harmful consequences occur </li></ul>Hazard <ul><li>Situation that might result in harmful consequences </li></ul>
    29. 29. Examples: <ul><li>An unsheathed needle lying on the floor is a hazard </li></ul><ul><li>The risk is that someone receives a needle stick injury </li></ul><ul><li>If the needle is picked up by a member of staff who places it, without injury, in a sharps box it was a near miss </li></ul><ul><li>If someone picks it up and injures themselves before putting it in a sharps box this is an incident </li></ul>
    30. 30. Incidents almost always involve a systematic failure <ul><li>Usually several factors have combined </li></ul><ul><li>It is rare that one person alone is responsible </li></ul><ul><li>Blame is more a matter of opinion than a matter of fact </li></ul>ACCIDENT
    31. 31. Identifying Hazards and Risks “ Comprehensive identification using a well-structured systematic process is critical” It is important to identify both things that have happened (retrospective identification) and those that might (prospective identification)
    32. 32. Types of Identification <ul><li>Example: </li></ul><ul><li>Specialist committees </li></ul><ul><li>(Infection Control, Drugs & Therapeutics, Resuscitation, H&S, Occupational Health) </li></ul><ul><li>Clinical effectiveness and records review </li></ul><ul><li>Hazard reporting </li></ul><ul><li>Risk assessments </li></ul><ul><li>Networking, use of media reports and information from other Boards </li></ul><ul><li>Example: </li></ul><ul><li>Incidents/near miss reporting </li></ul><ul><li>Claims </li></ul><ul><li>Complaints </li></ul><ul><li>Sickness and absence records </li></ul><ul><li>Staff turnover </li></ul><ul><li>Patient and staff satisfaction measures </li></ul><ul><li>Example: </li></ul><ul><li>Insurers </li></ul><ul><li>Internal audit function </li></ul><ul><li>Accreditation bodies' reports </li></ul><ul><li>Specialist inspections (e.g. HSA, Professional Bodies) </li></ul>Prospective Retrospective Prospective Internal Assessments Occurrences External Scrutiny and Inspection
    33. 33. Assessing Risks “ To avoid subjective bias, the best available information sources and techniques should be used when analysing consequences and likelihood .”
    34. 34. Measuring Risk A B Likelihood Consequences
    35. 35. Rating the incident <ul><li>Done in conjunction with line manager </li></ul><ul><li>Assists in managing risks through prioritisation </li></ul><ul><li>Rating of incident in respect of </li></ul><ul><ul><ul><li>Actual Severity </li></ul></ul></ul><ul><ul><ul><li>Future Likelihood </li></ul></ul></ul><ul><li>Extent of review determined by rating </li></ul>
    36. 36. Rating the Severity * Based on national comparisons In accordance with AS/NZS 4360:1999 Risk Management Standard Category Severity Quality & Prof. Guidelines Finance & Info . Fear, disempowerment & conflict of interest Safety (staff, patients/clients & NEHB population) Reputation/ Community Expectation (& Equity) Legal Requirements (and Equality) Low Minor non-compliance   < €5K Minor loss of info.   Minor cuts/ bruises Within unit Local press < 1 day coverage Minor out-of- court settlement. Minor legislative breach, no consequences Minor Single failure to meet internal standards or follow protocol   € 5K - €25K Claim below excess Verbal representation from minority groups. Concerns expressed by staff in 1 area/Dept .     Cuts/ bruises < 3 days absence < 3 days extended hospital stay Emotional distress Regulator concern Local press < 7 day of coverage Civil action Improvement Direction. Moderate Repeated failures to meet internal standards or follow protocols   € 25K - €1M Loss of or unauthorised access to confidential information Sustained campaign by minority group(s). Consistent indication of fear/concern across 1 or more sites   Single system injury e.g. fracture, > 3 days absence, 3-8 days extended hospital stay HSA reportable Semi-permanent physical/emotional trauma Regional/ National media < 3 day coverage Department notification/ executive action Class action – no defence Criminal prosecution Improvement Notice Severe Failure to meet national norms*/stds. Repeated failure to meet professional std.   € 1M - €5M Loss or corruption of key clinical information Judicial review finds conflict of interest. Collapse of management relations across Hosp. Group. Increased sickness absence/resignations >9 days extended hospital stay Fatality Permanent physical/emotional disability/trauma National media > 3 day of coverage Questions in the D áil . Independent external enquiry Criminal prosecution - no defence. Executive officer fined or imprisoned. Prohibition Notice . Catastrophic Gross failure to meet professional standards   > €5M Multiple Fatalities Multiple permanent physical/emotional injuries/trauma Full Public Enquiry Prohibition Notice Widespread culture of bullying.
    37. 37. Rating the Likelihood <ul><li>Rare – may occur only in exceptional circumstances </li></ul><ul><li>Unlikely – could occur at some time </li></ul><ul><li>Possible – might occur at some time </li></ul><ul><li>Likely – will probably occur in most circumstances </li></ul><ul><li>Almost Certain – is expected to occur in most circumstances </li></ul>
    38. 38. Risk Rating Matrix Catastrophic Severe Moderate Minor Low 5 4 3 2 1 Rare 10 8 6 4 2 Unlikely 15 12 9 6 3 Possible 20 16 12 8 4 Likely 25 20 15 10 5 Almost Certain Likelihood Severity
    39. 39. Recording the Outcome of the Assessment (The Risk Register) Having completed the assessment of risk, the outcome is entered onto a risk register. The risk register then becomes a summary of all known hazards/risks and is used to decide priorities for actions to control hazards/risks and to monitor the progress of those actions.
    40. 40. The Risk Register
    41. 41. Risk Control Options Eliminate Accept Transfer Reduce
    42. 42. Reducing Risk Likelihood Severity Risk Prevention Risk Mitigation
    43. 43. A unified but diverse team <ul><li>Both at corporate and local level support will be provided by a team of Advisors </li></ul><ul><li>Their job is to advise on risk issues, not manage them for you </li></ul><ul><li>Due to the range of skills needed, the individuals will have different specialisms. In particular: </li></ul><ul><ul><li>The Risk Advisor will take a lead on clinical risk issues </li></ul></ul><ul><ul><li>The Health & Safety Advisor will take a lead on safety and legislative compliance issues </li></ul></ul><ul><li>The skills may be diverse, but the objectives of each team member are the same [see RM Objectives] </li></ul>
    44. 44. Making it Happen “ The responsibility, authority and the inter-relationship of personnel who perform and verify work affecting risk management shall be defined and documented”
    45. 45. A Plan not a Strategy? IMPLEMENT MONITOR PLAN POLICY Local Risk Assessments Feedback on risks Prioritise resources/responses Training Actions Responsibility Results of risk assessments Incident Reporting Claims Complaints Audits/Inspections Sickness Absence
    46. 46. Important Risk Management Issues <ul><li>MEDICAL RECORDS: </li></ul><ul><li>Documentation (admission, antenatal , portogram, OT, postnatal & gynae notes). </li></ul><ul><li>Document the plan of management & WOMEN views. </li></ul><ul><li>Security </li></ul><ul><li>Confidentiality </li></ul><ul><li>Explanation , Discussion & Counselling </li></ul><ul><li>Consent </li></ul>
    47. 47. C0NCLUSION Blame culture “ We don’t make mistakes” culture “ So what” culture Silo or “tribal” culture “ not my business” culture Support don’t blame We all make mistakes Feedback & meaning Team culture It is everyone’s business