Risk Assessment

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Risk Assessment
Dr Mike Rejman Risk Assessment Adviser
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Why do Accidents Happen?
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Why do Accidents Happen?
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How do Accidents Happen?
Organisation and processes - Deficiencies
Prior conditions - basic causes contributory
factors
Unsafe acts - active failures (SRK errors)
Multiple Defences
Patient Safety Incident
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Understanding the Problem

• 80 of accidents are attributable to human
  factors, at the individual level, the
  organisational level, or more commonly both
• This is a conservative figure and is irrespective
  of domain
• To manage this we need to identify and understand
  the risks (causes and contributory factors)
• Without this we cant put appropriate remedial
  action in place

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Seven Steps to Patient Safety

• Build a safety culture
• 2. Lead and support your staff
• 3. Integrate your risk management activity
• 4. Promote reporting
• 5. Involve patients and the public
• 6. Learn and share safety lessons
• Implement solutions to prevent harm

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Step 3 - Integrated Risk Management

• All risk management functions and information
• patient safety,
• health and safety,
• complaints,
• clinical litigation,
• employment litigation,
• financial and environmental risk
• Training, management, analysis, assessment and
  investigations
• Processes and decisions about risks into business
  and strategic plans

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Risky Jobs
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Risky Jobs
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Risk Assessment by Donald Rumsfeld

• As we know,
• There are known knowns.
• There are things we know we know.
• We also know there are known unknowns.
• That is to say
• We know there are some things we know we do not
  know.
• But there are also unknown unknowns -
• The ones we dont know we dont know.

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The Accident Iceberg

• accidents
• serious incidents
• incidents
• near misses
• hazards
  
  
• 
  

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Prior Indicators of Risk

• Challenger Space Shuttle
• evidence of seals shrinking in cold temperatures,
  but political pressure to launch
• Columbia Space Shuttle
• long-standing problem with foam falling off (for
  9 years)
• even after Columbia disaster, a minority report
  noted at least 3 crucial issues not actioned
• this endangered Discovery

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Poor Design and Labelling
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Poor Design and Labelling
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Identifying Areas of Risk

• Retrospective learn lessons
• Accidents and incidents,
• Root Cause Analysis
• Prospective anticipate issues
• Reporting systems, near misses, reported hazards
• Prospective Risk Assessments, (proactive hazard
  assessment)

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Some Risk Assessment Methods

• HRA Techniques
• HEART
• Human Error Analysis and Reduction Technique
• THERP
• Technique for Human Error Prediction
• SHERPA
• Systematic Human Error Reduction and Prediction
  Approach
• GEMS
• Generic Error Modelling System
• IDEAS
• Influence Diagram Error Analysis System

• (H)FMEA
• (Healthcare) Failure Modes and Effects Analysis
• HACCP
• Hazard and Critical Control Points
• HAZOPS
• Hazard and Operability Studies
• PRA
• Probabilistic Risk Assessment
• SWIFT
• Structured What If Technique

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Risk Assessment Methods

• There are a great many methods
• Most were developed in safety-critical industries
  other than healthcare, only a few have been
  adapted to healthcare, with mixed success
• Problems over
• some quantitative, some qualitative
• whether they can combine factors or only treat
  them independently,
• issues over number generation
• few experimental comparisons, validation, or
  guidance
• some very resource intensive
• Which one to use?

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Risk Assessment Methods

• NPSA is developing two approaches to the issue
• (i) Patient Safety Research Fund longer term
  research to identify the best methods for
  healthcare and adapt methods if necessary. Will
  take 2 years to produce a toolbox
• (ii) Fast track pragmatic approach to produce
  guidance in the short-term

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Risk Assessments Four Basics Questions
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Lead to Four Management Options

• Terminate
• Treat
• Tolerate
• Transfer

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SWIFT

• Structured What IF checklisT
• Good technique for considering both human and
  organisational factors, as well as equipment
  factors, that may affect safety
• Structure
• Identification driven by
• Question driven
• What-if ?
• Checklist
• Best done using a multi-professional group

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Risk Assessment Flow DiagramAustralian/New
Zealand model

• Risk assessment is a PROCESS
• Helps to determine if systems, facilities or
  activities are acceptable
• Aid to decision making

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Record Sheet
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Risk Matrices

• Used for
• Qualitative assessment of the level of risk from
  an event
• Commonly used in risk assessments
• Found in many forms

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Risk Matrix

• Two dimensions
• Consequence
• (Also commonly called impact or severity)
• Likelihood
• (Also commonly called frequency or probability)
• How to use
• Define for a risk
• Its consequence
• Its likelihood
• Read off the risk level

Risk
Frequency/Likelihood/Probability
Consequence / Severity / Impact
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How to Use a Risk Matrix

• Identification of hazardous event/scenario
• Determining the risk using a risk matrix
• Assessment of the events/scenarios consequence
• Assessment of the events/scenarios likelihood
  of occurrence
• Determination of risk, (plotting scenarios on the
  risk matrix)
• Risk evaluation and decision making

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How to Use a Risk Matrix

• Assessment of the events/scenarios consequence
• May be a range of possible outcomes
• If possible chose outcome which is of regular
  concern
• (Otherwise assess risk for different outcomes)

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How to Use a Risk Matrix

• Assessment of the events/scenarios likelihood
• Note that the likelihood is for the outcome being
  considered
• Common error is to match event likelihood with
  worst case outcome which only happen in a
  minority of the event outcomes

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How to Use a Risk Matrix

• Determination of risk
• Plot scenario on the risk matrix

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Risk Evaluation and Decision Making

• The risk classes help drive risk mitigation
  decision making
• Common approach
• Where the risk is assessed as
• Low
• Evaluate as tolerable
• No risk mitigation recommendations needed
• High
• Evaluate as intolerable
• Risk reduction is required - aim to reduce medium
  or low
• Medium
• Evaluate as tolerable if ALARP demonstrated
• Practical and cost effective recommendations to
  reduce risk needed

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For Example - IT Systems

• Introducing IT systems can greatly increase
  capacity AND help eradicate certain errors
• BUT
• Unless systems are carefully designed to take
  account of human factors, they can actually
  increase errors and even introduce new ones, with
  catastrophic consequences

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New Technology in Airbus 320

• Glass cockpit and fly by wire state of the
  art technology
• Multifunction displays with many pages some of
  which are remarkably similar
• Operator awareness issues - leading to the
  introduction of a new error - mode error
• 87 people died in a crash at Strasbourg

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New Error
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Results from NPSA Funded Study on GP IT
Systems (University of Nottingham)

• Allergy alert may not be generated
• Hazard alert generated every third prescription
• Single keystroke to over-ride alert
• No audit trail
• Not all safety functionality activated (e.g.
  contra-indications)
• Hazards generated by drop-down menus (wrong
  selection made awareness)
• GPs unsure of safety functionality on systems
• Some think functionality is present when it isnt
  (e.g. contra-indications)

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Risk Assessment

• To ensure safe operation
• Systems and Processes need
• To be well designed (human factors) and
  thoroughly risk assessed
• To be more intuitive
• To make wrong actions more difficult
• To make correct actions easier (telling people to
  be more careful doesnt work)
• And it should be easier to discover error

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Hospital at Night (HaN) Risk Assessment Guide

• Presents an approach to risk assessing Hospital
  at Night solutions
• Available on the NPSA web site