1) Clinical risk management (CRM) aims to improve healthcare quality and safety by identifying and preventing circumstances that put patients at risk of harm. 2) Risk management involves risk identification, analysis, treatment, and control to minimize chances of errors and learn from past issues. 3) All healthcare staff have responsibilities for risk management including reporting incidents, identifying risks, and practicing risk prevention in their daily work.

1. Dr. Harris N Suharjono
Department of O&G
SGH

2. primum non nocere
(firstly, do no harm)

3. “Risk management is not
primarily about avoiding or
mitigating claims; rather, it is
a tool for improving the
quality of care.”

4. “Risk management is actually the
business of all stakeholders in
the organisation, doctors,
nurses, allied health staff, non
clinical personnel.”

5. 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.

6. 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?

7. Series of steps in CRM process

8. 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

9. 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.

10. 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

11. 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.

12. 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.

13. Inappropriate use of incident reporting
1. To performance manage a staff member
2. To allocate blame for an event
3. For personal grievances
4. For harassment or discrimination

14. 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

15. 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.

16. 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

17. 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 care
SECURITY:
 Adhere to all existing security procedures to ensure the
safety of our patients and babies

18. 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!