i just presented this one in our institution, please give the feed back, if you benifited from it. with compliments zulfat

1. By Team

2. SENERIO-----1
A 45-year-old female had gone to
ED triage and reported feeling
chest discomfort since 1 hr. She
developed cardiac arrest 15 minutes
after her arrival in the waiting
room.
The purpose of ED triaging is to
quickly assess and categorize
incoming patients and to identify
emergent patients. Patients who are

3. SENERIO----2

4. TEAM MEMBERS ARE
ZULFAT KAMALUDIN
ACHAMAMA MATHEW
LAKSHMI DURAISWAMI
CENLIN NAZRETH
LILLLYKUTTY JOSE
RUSY THANKACHAN
FROM A&E DEP.
KHOULA HOSP.

5. DEFINITION
Healthcare risk is the
chance of an adverse
outcome resulting
from clinical
investigation, treatment
or patient care.
National Patient Safety Agency 2007,NHS

6. .
This is the activities/measures
taken by health care authority
to prevent or mitigate the
occurrence or reoccurrence of a
real or potential (patient)
safety event.
(WHO, World Alliance for
Patient Safety 2009)

7. Identify, assess &manage the risk in order to
ensure the safety of both patient and staff.
Facilitate, promote and/or ensure appropriate
implementation of risk management in day-to-day
working
Reorganize systems and policies designed to
optimize risk management in the hospital setting.

9. Risk assessment questions
1. What can
go wrong?
2. How often?
3. How bad?
4. Is there a
need for
action?

10. RISK MANAGEMENT PROCESS

11. Trailing:-
One effective way of identification
of potential risk is to follow the
patient's trail. From triage
registration, waiting hall, clinical
encounter, investigation, treatment ,
documentation and disposal.

12. • Action slip or failure (e.g.
picking up the wrong medicine,
wrong label)
• Cognitive failure (e.g. ignorance
or misinterpreting a situation)
• Violations (deviations from safe
medication practices, procedures
or protocols) and breakdown in
documentation communication and
teamwork.
• LATENT FAILURE
• Fallible decisions made by
management levels.
• Examples are:-
• Heavy work load
• Inadequate knowledge and
supervision.
• Stressful environment, rapid

13. 1.Inaccurate triage categorization.
2. Prolonged waiting time
3. Failure in resuscitation management.
4. Failure in communications among caregivers &
patient.
5. Accidental fall.
6. Improper pain management
7.Shortage of health care workers.
8.Failure in documentation.
9.Failure in following standard protocol.
10.Not seeking help when necessary.
11.Medication errors,etc…

14. Assign an extensive knowledgeable
triage nurse .
Triage nurse should re asses the
waiting patients timely.
He/she should have adequate training
,competent skills and language.
Should be critical thinker &decision
maker .
If any doubt chose the
higher acuity to avoid
under triage.

15. Successful management of polytrauma depends on
the immediate diagnosis and management of the
most life-threatening injuries.
The systematic approach to a critically ill patient by
a team competent group of nurses and physicians
preserves a team’s focus and prevents errors
Authority should arrange mandatory courses for
all A&E staff to improve the professional
knowledge . So that all staff will be competent in
managing any emergency situation without any
failure in patients care.

16. Medication errors are a serious public
health threat, causing patient injury
and death and sharply increasing health
care costs.
Staff should aware about high-alert
medications which are known to cause
severe injury to patients when
administered.

17. CONT..
Minimize verbal orders and require that
medication orders to be entered electronically.
Design smooth workflow within the ED in a manner
that improves communication, minimize
interruptions and provides for double checks and
verbal confirmations before medications are given
to the patient.

18. If care is not documented assume it was
not rendered. Nurses’ notes are
recognized as documentary evidence.
IT SHOULD BE:
Factual,
Accurate,
Complete and
Timely

19. Ineffective communication is the most
frequently cited category of root causes of
sentinel events.
Effective communications can:
 Improve patient safety.
 Improve quality of care .
 Decrease length of patient stay.
 Improve patient and family satisfaction.
 Enhance staff morale and job satisfaction

21. Creation of a standing Risk Committee can
provide focus on risk as an important part of
emergency dep. also can encourage discussions of
ongoing risk reduction tools and programs.
QI programs help avert risk through the
processes of collecting data, performing chart
reviews, promoting appropriate documentation in a
peer-to peer-format and improving the quality of
care delivery.

22. Preventable trauma deaths should be reviewed in trauma
meeting.
Protocols, policies & procedures should be regularly reviewed
and updated
Routine reporting of incidents should be performed as a daily
activity and special rewards should be given to nursing staff
who report incidents, to motivate them towards incident
reporting as a means of risk identification and prevention
rather than punishment.
 Diplomatic and careful handling will pay great dividends.

24. Reducing risk and ensuring safety require greater
attention to systems that help to prevent and
mitigate errors.
 In order to improve the skills &knowledge authority
should arrange in-service courses &work shops.
Risk management and quality improvement efforts in
healthcare organizations are rallying behind patient
safety and finding ways to work together more
effectively and efficiently to ensure that their
organizations deliver safe and high-quality patient
care.

25. CONT..
While RM & QI department may separately address matters
related to the event, they can also share responsibilities.
The risk manager will assist with the disclosure of the event
to the patient and family . Both quality improvement and risk
management may be involved in conducting a root-cause
analysis of the event and preparing an action plan for
preventing similar events.

26. http://www.acep.org/education/graduate-medical-education/
academics/risk-management-outline-andresources-for-
educators/2012
Risk management in emergency department Hong Kong
Journal of Emergency Medicine , North District Hospital,
Accident & Emergency Department, 9 Po Kin Road, Fanling,
New Territori es, Hong Kong
Martin PB, Federico F. Risk management’s role in performance
improvement. Chapter 2, Volume 2. In: Carroll R, ed. Risk
management handbook for health care organizations. San
Francisco (CA): Jossey-Bass; 2006:23-35.
American Society for Healthcare Risk Management
(ASHRM): PDF FILE