Dear Colleagues,
I would like to this topic with you.
I have presented in one of the Khartoum conferences few years ago.
I felt it might be of value to some of you mainly those taking their second part exams or those providing safe women health services business.
1. Risk Management Awareness Raising Dr.Ahmed Eltigani Elmahdi Hussain Consultant Obstetrician&Gynaecologist Cavan General Hospital, IRELAND
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4. Risk Managent – Definitions …The culture, processes and structures that are directed towards the effective management of potential opportunities and adverse events Source: AS/NZS 4360 :1999 R M Standard …The process wherebye an organisation anticipates the potential for injuries or losses and acts to avoid those injuries before and/or to ameliorate them after they occur Source: R M in Health Care – Dr. G. Roberts
5. Risk Management - Process …The systemic appllication of management policies, procedures and practices to the task of establishing the context, identifying, analysing, evaluating, treating, monitoring and communicating risk Source: AS/NZS 4360 : 1999 R M tandard
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17. Clinical care The environment of care Financial resources CLINICAL GOVERNANCE ORGANISATIONAL CONTROLS FINANCIAL CONTROLS Health & Safety Human Resources Integrated Care Due Diligence Risk Strategy Quality Reviews Risk Reviews Clinical Audit Practice Developments Claims Management Education & training Performance Management Re-engineering of Systems Service Continuity Planning Healthcare Risk Management
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19. Establish Context Identify Risks Analyse Risks Treat Risks MON I TOR Evaluate Risks The Context – The Risk Management Process AS/NZS 4360:1999 Risk Management Standard COMMUNI CATE
20. Stop it Accident Incident Investigation Task Person Discipline them Past Approach: Person centred investigations Situation ??????
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22. Defence Barriers J. Reason 1994 Case Analysis Using Reason’s Statistical failures in defences Organisational Accident Causation Model
23. J. Reason 1994 Case Analysis Using Reason’s Organisational Accident Causation Model Statistical failures in defences Situation Task Errors Violations Corporate Culture Management decisions and organisational processes Local climate Error- producing conditions Violation- producing conditions Defence Barriers Latent failures in defences
24. Focus on process not individual “ People and perfect processes make a quality health service. Poor quality results from a badly designed and operated process, not from lazy or incompetent health care workers” Source: John Øvretviet, 1992 Health Service Quality
25. And Risk Management involves….. (AS/NZS 4360 and HSA “Workplace Health & Safety Management” ) IMPLEMENT MONITOR & REVIEW PLAN POLICY
31. Identifying Hazards and Risks “ Comprehensive identification using a well-structured systematic process is critical” It is important to identify both things that have happened (retrospective identification) and those that might (prospective identification)
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33. Assessing Risks “ To avoid subjective bias, the best available information sources and techniques should be used when analysing consequences and likelihood .”
36. Rating the Severity * Based on national comparisons In accordance with AS/NZS 4360:1999 Risk Management Standard Category Severity Quality & Prof. Guidelines Finance & Info . Fear, disempowerment & conflict of interest Safety (staff, patients/clients & NEHB population) Reputation/ Community Expectation (& Equity) Legal Requirements (and Equality) Low Minor non-compliance < €5K Minor loss of info. Minor cuts/ bruises Within unit Local press < 1 day coverage Minor out-of- court settlement. Minor legislative breach, no consequences Minor Single failure to meet internal standards or follow protocol € 5K - €25K Claim below excess Verbal representation from minority groups. Concerns expressed by staff in 1 area/Dept . Cuts/ bruises < 3 days absence < 3 days extended hospital stay Emotional distress Regulator concern Local press < 7 day of coverage Civil action Improvement Direction. Moderate Repeated failures to meet internal standards or follow protocols € 25K - €1M Loss of or unauthorised access to confidential information Sustained campaign by minority group(s). Consistent indication of fear/concern across 1 or more sites Single system injury e.g. fracture, > 3 days absence, 3-8 days extended hospital stay HSA reportable Semi-permanent physical/emotional trauma Regional/ National media < 3 day coverage Department notification/ executive action Class action – no defence Criminal prosecution Improvement Notice Severe Failure to meet national norms*/stds. Repeated failure to meet professional std. € 1M - €5M Loss or corruption of key clinical information Judicial review finds conflict of interest. Collapse of management relations across Hosp. Group. Increased sickness absence/resignations >9 days extended hospital stay Fatality Permanent physical/emotional disability/trauma National media > 3 day of coverage Questions in the D áil . Independent external enquiry Criminal prosecution - no defence. Executive officer fined or imprisoned. Prohibition Notice . Catastrophic Gross failure to meet professional standards > €5M Multiple Fatalities Multiple permanent physical/emotional injuries/trauma Full Public Enquiry Prohibition Notice Widespread culture of bullying.
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38. Risk Rating Matrix Catastrophic Severe Moderate Minor Low 5 4 3 2 1 Rare 10 8 6 4 2 Unlikely 15 12 9 6 3 Possible 20 16 12 8 4 Likely 25 20 15 10 5 Almost Certain Likelihood Severity
39. Recording the Outcome of the Assessment (The Risk Register) Having completed the assessment of risk, the outcome is entered onto a risk register. The risk register then becomes a summary of all known hazards/risks and is used to decide priorities for actions to control hazards/risks and to monitor the progress of those actions.
44. Making it Happen “ The responsibility, authority and the inter-relationship of personnel who perform and verify work affecting risk management shall be defined and documented”
45. A Plan not a Strategy? IMPLEMENT MONITOR PLAN POLICY Local Risk Assessments Feedback on risks Prioritise resources/responses Training Actions Responsibility Results of risk assessments Incident Reporting Claims Complaints Audits/Inspections Sickness Absence
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47. C0NCLUSION Blame culture “ We don’t make mistakes” culture “ So what” culture Silo or “tribal” culture “ not my business” culture Support don’t blame We all make mistakes Feedback & meaning Team culture It is everyone’s business
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Editor's Notes
The nuclear and aircraft industries were the first to develop formal methods for risk management in the 1950’s. Following the Flixborough disaster the chemical industry adopted these formal methods and developed further techniques (for example, HAZOP). The oil and gas industry began to take risk management seriously after Piper Alpha, and the Transport sector following the Clapham Junction crash and Kings Cross fire. The push for the Finance Sector came from Barings Bank. It is interesting to note that the Paddington crashes occurred after they had apparently put all of the necessary safety systems in place. Reviews of those crashes agree that all the right systems were in place, but that the culture in the organisations was wrong.
In 1991 a famous study was conducted in the US (known as the “Harvard Study”) where a large number of patient records, and corresponding outcomes, were reviewed retrospectively. The reviewers were asked to identify where there was clear evidence that patients had been harmed by their care while in hospital and where this had led to significant detriment to the outcome. The results were shocking, and led to further studies and then action supported directly by the then US President. These included the establishment of national systems (e.g. Sentinel Event Reporting) to reduce the levels of such occurrences. The US study was repeated in the UK and the levels of medical error were, unsurprisingly, found to be similar. A further study in Australia has found similar evidence. The Australian studies were undertaken in 1995 and 1999 and showed a much higher rate – 16.6%. The UK study was in 2000 and showed a 10.8% rate (comparable with the 4% and 16.6% and thus coming in about the middle). A 2000 study in New Zealand came out at 10.7% No such study has yet been conducted in Ireland but it would be remarkable if the levels of error here were much better then those in the U.S., Australia and the UK. What was regarded as one of the most shocking statistics in all of these studies was the number of avoidable deaths that occur. In the UK study it was estimated nationally to be 40,000 each year making it one of the most common causes of death! It should be noted that the researchers are now extremely wary of extrapolation, giving various reasons why you can’t extrapolate. Medical staff in particular may ask questions about the research and the definitions etc. However, this is irrelevant as the extrapolations are now widely reported (including in the press) and the health service has a job on its hands both internally in terms of reducing error and externally in terms of PR!!