Risk Management in Healthcare

1. Risk Management
Orientation
By
Dr. Nashwa Elsayed
Patient Safety & Risk Manager
Accreditations Manager
King Fahd Hospital - Medina

2. Our Meeting Objectives
■ Why Risk Management In Healthcare?
■ Risk Management Concepts
■ Risk Register
■ OVA / Incident Reporting & Management.
■ Sentinel Event Reporting & Investigation
■ Risk Management Coordinator Job Description
■ Risk Management Policies
Dr. Nashwa Elsayed
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3. WHY RISK MANAGEMENT IN
HEALTHCARE?
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5. According to Agency for Healthcare Research and Quality
(AHRQ) Report 2013
Rate of harm associated with hospital stays in U.S hospitals
is 25 per 100 admissions.
According to Institute for Healthcare improvement (IHI)
Medical errors have become the third leading cause of death in
the United States each year, behind cancer and heart disease.
Why Risk Management In Healthcare??
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8. RISK MANAGEMENT CONCEPTS
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11. Risk Perception
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12. Swiss Cheese Model
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Hazards

13. Swiss Cheese Model
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14. Risk Management
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15. is a process that is made up of three processes:
1. Risk Identification: is a process that is used to Find, Recognize & Describe the risks that
could affect the achievement of objectives.
2. Risk Analysis: is a process that is used to Understand The Nature, Sources & Causes of the
risks that have been identified and to estimate the level of risk. lt is used to study Impacts And
Consequences and to examine the controls that currently exist.
3. Risk Evaluation: is a process that is used to compare risk analysis results with risk criteria
in order to determine whether or not a specified level of risk is acceptable or tolerable.
Risk Assessment
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16. Root Cause Analysis (RCA)
Is a Reactive approach process for identifying causal factors that bring variation in
performance, focuses primarily on systems and processes, not on individual
performance.
Failure Mode & Effect Analysis (FMEA):
Is a Proactive approach of identifying and preventing process problems before they occur.
RCA vs FMEA
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17. RISK REGISTER
RISK REGISTER 20201. JANUARY - 20204. NURSING - JANUARY 2020.XLSX
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18. The Risk Register is essential tool for documenting Risks and Actions to
manage each risk.
Three Levels Of Risk Register:
First Level: Departmental / Ward / Unit Level
Second Level: Example - Surgical, Medical, Administrative
Third Level: The Board Level - Corporate Risk Register
Risk Register
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20. Risk Score Calculation by Risk Registry
Risk Score (RS) =
Likelihood (L) x Impact (I)
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25. OVA / INCIDENT
REPORTING & MANAGEMENT
HWP-161 REPORTING AND MANAGEMENT OF OCCURRENCE VARIANCE ACCIDENT.PDF
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26. Any unplanned or unintended event or circumstances which could have resulted or did result in
harm to a patient.
1. Harmful
2. No Harm
3. Near Miss
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Incident

27. 1. Act Of Commission (doing something wrong)
2. Act Of Omission (failing to do the right thing)
Leading To An Undesirable Or Significant Outcome
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Medical Errors

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30. An undesired outcome or occurrence, not expected within the normal course of
care or treatment, disease process, condition of the patient or delivery of
services
Unintended Physical Injury resulting from or contributed to by medical care
(including the absence of indicated medical treatment), that requires additional
monitoring, treatment ,hospitalization or that results in death.(IHI)
Could be Preventable or Non-preventable
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Adverse Event

31. An event or situation that could have resulted in an accident, injury,
or illness but did not, either by Chance or by Timely Intervention.
e.g., a procedure almost performed on the wrong patient due to lapse in
verification of patient identification but caught at the last minute by chance)
Good Catch
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Near miss

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OVA Management

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OVA Management

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OVA Management

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OVA Management

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OVA Management

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OVA Management

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39. SENTINEL EVENT
REPORTING & INVESTIGATION
HWP-160 REPORTING AND INVESTIGATION OF SENTINEL EVENTS AND ACTION PLAN.PDF
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40. An unfortunate, but occasional Serious Adverse Event involving a
patient
It must be Quickly & Comprehensively Investigated, Evaluated, &
Analysed to identify every possible modification or change in patient
care delivery systems which might prevent similar adverse events in
the future & prevent it.
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Sentinel Event

41. 1. An unanticipated death, including, but not limited to,
1.1. Death that is unrelated to the natural course of the patient’s illness or underlying condition.
1.2. Death of a full-term infant
1.3. Suicide
1.4. Unexpected Death
2. Major permanent loss of function unrelated to the patient's natural course of illness or underlying
condition
3. Wrong-site, wrong-procedure, wrong-patient surgery
4. Transmission of a chronic and or fatal disease or illness as a result of infusing blood or blood products
or transplanting contaminated organs or tissues.
5. infant abduction or an infant sent home with the wrong parents.
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Sentinel Event include any of the following criteria, but is
not limited to

42. 6. Rape, workplace violence such as assault (leading to death or permanent loss of function); or homicide
(wellful killing) of a patient, staff member, practitioner, medical student, trainee, visitor, or vendor while on
hospital property.
7. Wrong Patient.
8. Major Medication Error Leading to Death or Major Morbidity.
9. Maternal Death
10. Haemolytic Blood Transfusion Reaction.
11. Retained instruments or a Sponge.
12. intravascular Gas Embolism.
13. Unexpected Loss of a Limb or a Function.
14. Medical equipment or device related error/dysfunction leading to death or permanent harm
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Sentinel Event include any of the following criteria, but is
not limited to

43. 1. Unexpected unplanned return to operating room
2. Unplanned blood transfusion
3. Unscheduled return to emergency room after discharge from the ward (within 72 hours)
4. Wrong implant or prosthesis
5. Injury or unplanned repair or removal of an organ
6. Complication post ERCP
7. Complication post angiogram
8. IVH grade lll/lV
9. lnjury to Common Bile Duct during Laparos3copic Cholecystectomy
10.Venous thromboembolism
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All identified mandatory reportable events (MRE) must be
reported to the MOHMRE website.

44. RISK MANAGEMENT COORDINATOR
JOB DESCRIPTION
HWP-326 JOB DESCRIPTION (JD)- RISK MANAGEMENT COORDINATOR.PDF
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46. RISK MANAGEMENT POLICIES
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47. HWP-160 Reporting and investigation of sentinel events and action plan
HWP-161 Reporting And Management Of Occurrence Variance Accident
HWP-162 Root Cause Analysis (RCA)
HWP-184 Near Miss Policy
HWP-327 Risk Management Policy And Procedure
HWP-328 Just Culture
HWP-329 Disclosure Of Patient Safety Events
Risk Management Policies
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48. THANK YOU