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Quality Education for a healthier Scotland
THE BASICS OF RISK MANAGEMENT
Quality Education for a healthier Scotland
Housekeeping
Quality Education for a healthier Scotland
STRUCTURE FOR THE DAY
• Risk Management recap
• Risk Management under the microscope
• Tools and Techniques
• Patient Safety Case Study
Quality Education for a healthier Scotland
Risk Management recap
Quality Education for a healthier Scotland
Risk is ….
The management of UNCERTAINTY to increaseincrease the probability
of success success and reducereduce the probability of failurefailure.
Risk is inherent to any activity, has the potential to affect your success, and can be both negativenegative and positivepositive.
With risk comes opportunities for growthgrowth and developmentdevelopment.
It can be shaped but notnot totally eliminatedeliminated!
Quality Education for a healthier Scotland
Quality Education for a healthier Scotland
What is Risk Management in NHS Scotland
Risk management is the systematic identification, assessment and reduction of risks to patients, staff and the organisation (NHS HIS)
Risk management proactively reduces identified risk to an acceptable level by creating a culture founded on assessment and prevention rather than reaction and remedy. (NHS HIS)
The aim of risk management is to create a culture in which NES staff and stakeholders are aware of risk and its potential impact, and in which they are aware of their responsibilities in relation to the management of risk, thereby promoting an open and responsive approach to risk management which actively involves all elements of NES.
(NHS Education for Scotland)
Quality Education for a healthier Scotland
We all naturally manage risk every day…..
Quality Education for a healthier Scotland
14 storey building
Quality Education for a healthier Scotland
Quality Education for a healthier Scotland
Benefits of Risk Management
• Supports strategic and business planning• Promotes continuous improvement and identification of new opportunities• Encourages innovation and creativity• Engenders a proactive outlook• Ensures robust contingency planning • Improves our ability to meet objectives and achieve opportunities• Reduces shocks and unwelcome surprises• Advocates transparency • Furthers compliance with governance agenda • Stimulates regular review and monitoring of business processes• Enforces ownership• Provides for effective use and prioritisation of resources• Reassures staff, stakeholders and governing bodies• Enhances communications internally and with external stakeholders• More informed decision-making.
Quality Education for a healthier Scotland
Risk Management under the microscope
Quality Education for a healthier Scotland
Identifying and Managing a Risk
Identify the risk
Evaluate the risk
Risk response (ownership and
priority)
Monitor and review
Plan / implement additional
actions
Manage the Risk
Quality Education for a healthier Scotland
How to identify a Risk - some questions to ask
Risk Management relates to the identification of uncertainties and what actions could be taken to mitigate against them, or even encourage them.
* Has this event happened before in our organisation (or a team) or in another similar organisation? Could it happen again?
* What are the key dependencies / core processes / routine operations of our organisation (or a team)? Are there any possible things that could affect their continuity?
* What are our main objectives? What might prevent them from being achieved?
* Are there any new activities / developments / products / improvements that could impact existing functionality or bring in new risks for us (or a team)? What can be done in mitigation?
* What opportunities are there that we could benefit from?
* Does the event relate to our Accountability/Governance requirements; our Financial position; our Operations / Service Delivery; our Reputation or Credibility; Health & Safety?
Quality Education for a healthier Scotland
Sources of Risks
Risks to the project / function / activity’s existence
- strategic direction / policy change; funding / staff withdrawal
Risks from within the project / function / activity
- overspending; over-run; poor quality end-product
External Risks (more difficult to predict)
- customer / stakeholder pressures; socio-political pressures; environmental pressures
Quality Education for a healthier Scotland
Identifying and Managing a Risk
Identify the risk
Evaluate the risk
Risk response (ownership and
priority)
Monitor and review
Plan / implement additional
actions
Manage the Risk
Quality Education for a healthier Scotland
reduces impact
REACTIVE
reduces likelihood of loss
PROACTIVE
removes
Evaluate the Risk - Risk Decision Path
TERMINATE?
TRANSFER?
TREAT?
TOLERATE
(no)
(no)
(no)
risk eradicated, however inaction may lead to other risks
risk subcontracted risk occurrence insured against
controls in place to reduce likelihood of risk occurring
actions in place to deal with risk when it occurs
(yes)
(yes)
(yes)
Quality Education for a healthier Scotland
Identifying and Managing a Risk
Identify the risk
Evaluate the risk
Risk response (ownership and
priority)
Monitor and review
Plan / implement additional
actions
Manage the Risk
Quality Education for a healthier Scotland
Prioritising Risks
In NHS Scotland Risk is measured in terms of its impact and likelihood:
Impact - a reflection of the pain or loss or discomfort that may be caused by an event
Likelihood - an indication of how often we can expect a particular event to occur
In NHS Scotland, risk is scored on a 5 x 5 matrix and ranges from negligible to catastrophic
Risk is summarised into Low, Medium (Housekeeping or Contingency) and Primary risks.
Quality Education for a healthier Scotland
NES Scoring Matrix
Quality Education for a healthier Scotland
Managing a Risk - jargon
Corporate Governance
The system by which companies are directed and controlled
Event
The occurrence of a particular set of circumstances
Mitigation
The act of making a consequence less severe
Issues v Risks?
Risks are things that might happen, issues are things that are actually happening
Controls v Actions?
Controls are mitigation measures already in place, actions are new controls that we are currently working on.
Quality Education for a healthier Scotland
We are all personally responsible for managing risks …
Quality Education for a healthier Scotland
The Cumulative Act EffectThe SWISS CHEESE of Risk Management
James Reason 1990
Quality Education for a healthier Scotland
Reasons for latent failure
Inadequate communication
Quality Education for a healthier Scotland
Significant Event Analysis (SEA)
Carried out in individual cases in which anyone in the team thinks there has been a significant occurrence (not necessarily involving an undesirable outcome for the patient) are analysed in a systematic and detailed way to ascertain what can be learnt about the overall quality of care and to indicate changes that might lead to future improvements
Quality Education for a healthier Scotland
Root Cause Analysis (RCA)
A structured approach to identifying the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes (consequences) of one or more past events in order to identify what behaviours, actions, inactions, or conditions need to be changed to prevent recurrence of similar harmful outcomes and to identify the lessons to be learned to promote the achievement of better consequences.
Quality Education for a healthier Scotland
Problem Solving - Some tools and techniques
Bono’s Six Thinking HatsBrainstormingPEST(LE)SWOTFive Why’s / So What
Ishikawa Fishbone Barrier Analysis
Significant Event AnalysisRoot Cause Analysis
Quality Education for a healthier Scotland
Barrier Analysis
Technique used in Root Cause Analysis or Significant Event Analysis, and can be used reactively to solve problems or proactively to evaluate existing barriers.
The term “barrier” is used to mean any barrier, defence or control that is in place to increase the safety of a system.
Four types of barrier – Physical; Natural; Human Actions; Administrative1. Identify the process to be reviewed2. Identify all control measures in place3. Ensure you have Physical and Natural barriers (failsafe)4. Consider additional control measures that would be useful5. Consider the cost:benefit of additional measures6. Assign ownership and action new additional measures 7. Repeat regularly (Proactive Barrier Analysis Dineen 2002)
Quality Education for a healthier Scotland
Quality Education for a healthier Scotland
Inadvertent Harm A Case Study
Quality Education for a healthier Scotland
Inadvertent Harm
This is a case study prepared by the National Patient Safety Agency in England and is based on a real incident.
In 1968, vincristine was first administered intrathecally (ie into the spine) in error to a young patient with acute lymphocytic leukaemia. She died 3 days later.
Intrathecal administration of vincristine is a rare event but catastrophic for the patient, family and clinical team involved. Over 40 years, 58 cases of intrathecal vincristine errors are known to have occurred across the world.
Quality Education for a healthier Scotland
Timeline - characters
Charlotte Green Pharmacist Tech Mr Shah
Pharmacist
Liam Short Staff Nurse
Abe Kamole Staff Nurse
Ann Lynch Ward Sister
Helen Roberts Relief Sister
Jane Hughes Patient
Jazmin Munroe Consultant
Fiona Livingstone Specialist Registrar
Duncan Campbell New Specialist
Registrar
Joe Robinson Relief Junior
Doctor
Quality Education for a healthier Scotland
Inadvertent harm – timeline variations
Before the day
Patient and Consultant agree to IV and IT treatment on same day
On the day
Pharmacist issues Vincristine (IV) and Methotrexate (IT)
Ward Sisters in charge unable to handover at shift change
Patient arrives late
Ward SpR unexpectedly leaves Ward
Patient taken to dedicated bay and plugs into her walkman
Staff Nurse called away to emergency
Locum SpR and SHO left alone to administer chemotherapy drugs.
Quality Education for a healthier Scotland
Thinking back to your pre course reading:
• What prevention barriers were in place?
• Did the barrier work?
• If it failed, why?
• How did the barrier affect the consequence of the event?
What could you do to try to prevent an incident of healthcare associated harm occurring in the future?
What lessons could be learned from such an incident?
Inadvertent Harm
Quality Education for a healthier Scotland
No Blame
In NHS, when a serious incident occurs, in order to fully learn from the event, a policy of no blame is taken (you don’t usually come to work planning to deliberately harm someone or do a bad job!)
But what could the pharmacy staff in particular have done differently?• Vincristine (IV) and Methotrexate (IT) should not have been issued on
same day, Pharmacist raises concern but is over-ridden;• Pharmacist Technician knows she should not dispense the
Methotrexate (IT) to someone who is not on the register, but is over-ridden;
• Pharmacist Technician does not confirm that the Vincristine (IV) has been administered before dispensing the Methotrexate (IT);
• Pharmacist Technician does not confirm that the Methotrexate (IT) will be administered immediately to the patient and not stored on the ward.
Quality Education for a healthier Scotland
General Lessons to be learned
CAUSE EFFECT
Lack of proper handover at various points poor communication
No competency test required for administration of drug
inadequate and out of date policy
Senior officer completely absent but accountable
assumes staff will fulfil wishes without clarifying them
Dr Livingstone leaves unexpectedly / Sister Lynch leaves early / SN Abe called to emergency
suitably qualified staff not present when needed
Dr Campbell not on IT register, busy environment leads to lack of concentration
hierarchy overrides written policy, Pharmacist Technician should not have dispensed Methotrexate (IT)
Patient taken to IT bay even though no IV drug administered yet
over-reliance on policy and procedure
Drug bag checked for patient details but not drug contents
half application of policy leads to comfort that the entire policy is being adhered to.
Two chemo drug fridges breach of policy and also not sufficiently labelled for outside people to use properly
Dr Campbell sends Dr Robinson to “get the chemo”
use of jargon which is easily misinterpreted
Quality Education for a healthier Scotland
Inadvertent Harm – an afterthought
Route delivery errors account for approximately 5% of medication errors. (Bates DW, Boyle DL, et al “Relationship between medication errors and adverse drug events.” J Gen Intern Med 1995;10:199–205.)
Such incidents attract serious incident enquiries and proposals have been made involving the physical redesign of delivery systems such that it is impossible to deliver drugs by the wrong route.
To date, an international agreement on such standardisation is yet to be reached.
Quality Education for a healthier Scotland
Summary - We are all risk managers
• Everyone in the organisation is involved in the management of risk
• Risk is a proactive tool in supporting and informing decision-making
• Any time is a good time to review the risks in your work area and plan
mitigations to prevent them / cope when they occur
• If you are commencing a new project or large piece of work, your
planning would be aided by considering the risks and introducing
controls to mitigate against them happening or take steps to reduce
their impact if they are not preventable.
Quality Education for a healthier Scotland
Today we have covered
• Risk Management recap
• Risk Management under the microscope
• Tools and Techniques
• Case Study
Quality Education for a healthier Scotland
Thank you for participating
Any questions?