Lecture at the I Panamerican Congress of Hospitalists, held in Brasil Nov/2010. Deals with risk basic concepts in hospitals and helath industry.

1. Dr. Sami A. R. J. El Jundi, MD, MSc
Forensic Advisor & Risk Analyst
Medico-legal Expert in Medical Malpractice Lawsuits
Coordinator of the Medical Law Postgraduate Course at VJ/Porto Alegre

2. In politics, “law and order” refers to demands for
a strict criminal justice system, especially in
relation to violent and property crime, through
harsher criminal penalties.
Supporters of "law and order" argue that effective
deterrence combined with incarceration is the
most effective means of crime prevention.
Opponents of law and order argue that a system
of harsh criminal punishment is ultimately
ineffective because it does not address
underlying or systemic causes of crime.
http://en.wikipedia.org/wiki/Law_and_order_(politics)

3. Plastic surgeons charged for second-degree
murder (a killing caused by dangerous
conduct and the offender's obvious lack of
concern for human life)
Criminal prosecution by the DA’s Office
Physicians facing the risk of incarceration due
to patient loss
Criteria for charging: “procedure futility” and
“unproportional damage” (res ipsa loquitur)

4. A body of knowledge (methodology) that
evaluates and derives a probability of an
adverse effect of an agent (chemical,
physical, or other), industrial process,
technology, or natural process.
Definition of an "adverse effect" is a value
judgement.

5. Risk analysis applied in a particular situation
Deal with health effects or, more recently,
with the ecological health or economic well-
being (in case of business risk analysis).

6. 1. Hazard (agent) identification
2. Dose-response relationship (how is quantity,
intensity, or concentration of a hazard related
to adverse effect)
3. Exposure analysis (who is exposed? to what and
how much? how long? Other exposures?)
4. Risk characterization (reviews all of the
previous items and makes calculations based
on data, with all the assumptions clearly stated;
often the conclusion is that more data and/or
improvement in methodology is needed and
that no numerical risk number can be derived
to express accurately the magnitude of risk)

7. Deciding WHAT is an adverse effect (and to
some extent hazard identification) is a value
judgment that can be made by well-informed
citizens.
◦ It could be defined as death or disease (in most cases of
human health risk analysis); it could be a failure of a
nuclear power plant, or a chemical plant accident, or a
loss of invested money. In some recent cases of risk
analysis, even vaguely defined terms such as “quality of
life” or “sense of community” have been evaluated using
risk analysis.

8. “Yet the confidence in the unlimited power of
science is only too often based on a false
belief that the scientific method consists in
the application of a ready-made technique, or
in imitating the form rather than the
substance of scientific procedure, as if one
needed only to follow some cooking recipes
to solve all social problems.”
Hayek FA. 1991. Economic Freedom. Cambridge, MA (Oxford, UK).
Basil Blackwell Ltd. p. 287

9. The very word risk implies uncertainty.
The uncertainty in a risk assessment changes
with time as information develops.
Different uncertainties in risk estimation:
◦ Stochastic uncertainty (largely random)
◦ Type A and Type B uncertainties (variability vs.
uncertainty)
◦ Systematic uncertainty
◦ Subjective uncertainty (disagreement among those
assessing the risks)

10. The word “error” that is used in formal statistical
theory has another connotation when used in
discussions of public health and medicine and
can mean “mistake”.
Therefore, the words “uncertainty analysis”
replace “theory of error”.
In reactor safety analyses, for example, the
postulated initiating event is often someone’s
mistake or error.
An analysis of the frequency and distribution of
these mistakes is an important input to any full
probabilistic risk analysis (PRA).

11. Adverse outcome
Adverse event
Error
Preventable adverse event
Negligence

12. 1. Noncancer chemicals risk analysis (Hazard)
2. Carcinogen risk analysis (Hazard)
3. Epidemiological risk analysis (which could
include both cancer and noncancer
chemicals or other nonchemical hazards,
such as accidents, electromagnetic
radiation, nutrition, etc.)
4. Probabilistic risk analysis associated with
nuclear power plant safety and chemical
plant safety

13. 5. A posteriori risk analysis, which is applied in
actuary science to predict future losses,
either from natural phenomena,
investments, or technology
6. Nonquantitative risk analysis, or “common
sense” risk analysis, which can give only
vague patterns of possible risks.
7. Systematic risk profiling
8. Comparative risk analysis

14. The thought process that goes into evaluating
a particular hazard is more important than
the application of some sophisticated
mathematical technique or formula, which
often may be based on erroneous
assumptions or models of the world.

15. Potentially involved players after an adverse
event:
◦ Clinical staff
◦ Legal staff
◦ Hospital and/or practice administration
◦ Risk managers or advisors
◦ Quality/safety improvement personnel
◦ Patients relatives
◦ Media public

16. 1. Oriented by previous experience
2. Subjective
3. Informal
4. Caotic / not standardized
5. Usually not measured
6. Frequently not fully understood
7. Hospital as a care (“safer”) place

17. 7. Awareness after catastrophic events,
with short “half life”
8. Expensive to manage
9. Creates vulnerability for hospital and
doctors
10. Support “witch-hunts” and lawsuits
11. Medical attention is individually
shaped and not suitable for
staging/planning

18. “More research is needed not only in thinking
through the process of care but also in
showing that the heightened awareness of
risk improves patient outcomes.
Implementing such an approach to define risk
requires more than a distant external risk
expert to map the process of care and
document the risks.
Health professionals need to be actively
engaged.”
Donaldson, LJ; Noble, DJ. The need for risk profiling in
patient safety. J Patient Saf, 6(3):125-7. Sep/2010.

19. “Voluntary” reduction in risks from pollution
and technological risks in general are best
achieved by designing and enforcing
intelligent environmental and occupational
laws.
Carrots and sticks may be more effective in
dealing with environmental and occupational
risks (accidents or pollution) than either
sticks or carrots alone!

20. 1. Healthcare is a high-risk industry
2. Healthcare has the lowest awareness
among high-risk industries (eg. F1)
3. Society has become more and more
aware of its own safety
4. To err (once) is human, twice may be
criminal

21. samieljundi@risk-0.com