Title: THE BASICS OF RISK MANAGEMENT
1THE BASICS OF RISK MANAGEMENT
2Housekeeping
3STRUCTURE FOR THE DAY
- Risk Management recap
- Risk Management under the microscope
- Tools and Techniques
- Patient Safety Case Study
4Risk Management recap
5Risk is .
- The management of UNCERTAINTY to increase the
probability - of success and reduce the probability of
failure. - Risk is inherent to any activity, has the
potential to affect your success, and can be both
negative and positive. - With risk comes opportunities for growth and
development. - It can be shaped but not totally
eliminated!
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7What 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)
8We all naturally manage risk every day..
914 storey building
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11Benefits 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.
12Risk Management under the microscope
13Identifying and Managing a Risk
Monitor and review
Identify the risk
Plan / implement additional actions
Evaluate the risk
Manage the Risk
Risk response (ownership and priority)
14How 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/Gove
rnance requirements our Financial position our
Operations / Service Delivery our Reputation or
Credibility Health Safety?
15Sources of Risks
- Risks to the project / function / activitys
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
16Identifying and Managing a Risk
Monitor and review
Identify the risk
Plan / implement additional actions
Evaluate the risk
Manage the Risk
Risk response (ownership and priority)
17Evaluate the Risk - Risk Decision Path
removes
risk eradicated, however inaction may lead to
other risks
reduces
likelihood of loss
PROACTIVE
risk subcontracted risk
occurrence insured against
controls in place to reduce likelihood of risk
occurring
reduces
impact REACTIVE
actions in place to deal with risk when it occurs
18Identifying and Managing a Risk
Monitor and review
Identify the risk
Plan / implement additional actions
Evaluate the risk
Manage the Risk
Risk response (ownership and priority)
19Prioritising 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.
20NES Scoring Matrix
21Managing 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.
22We are all personally responsible for managing
risks
23The Cumulative Act EffectThe SWISS CHEESE of
Risk Management
James Reason 1990
24Reasons for latent failure
25Significant 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
26Root 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.
27Problem Solving - Some tools and techniques
- Bonos Six Thinking Hats
- Brainstorming
- PEST(LE)
- SWOT
- Five Whys / So What
- Ishikawa Fishbone
- Barrier Analysis
- Significant Event Analysis
- Root Cause Analysis
28Barrier 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 Administrative - Identify the process to be reviewed
- Identify all control measures in place
- Ensure you have Physical and Natural barriers
(failsafe) - Consider additional control measures that would
be useful - Consider the costbenefit of additional measures
- Assign ownership and action new additional
measures - Repeat regularly
(Proactive Barrier Analysis Dineen 2002)
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30Inadvertent Harm A Case Study
31Inadvertent 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.
32Timeline - characters
Jazmin Munroe Consultant
Charlotte Green Pharmacist Tech
Mr Shah Pharmacist
Jane Hughes Patient
Duncan Campbell New Specialist Registrar
Liam Short Staff Nurse
Helen Roberts Relief Sister
Abe Kamole Staff Nurse
Fiona Livingstone Specialist Registrar
Joe Robinson Relief Junior Doctor
Ann Lynch Ward Sister
33Inadvertent 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.
34Inadvertent Harm
- 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?
35No Blame
- In NHS, when a serious incident occurs, in order
to fully learn from the event, a policy of no
blame is taken (you dont 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.
36General 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
37Inadvertent 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
199510199205.) - 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.
38Summary - 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.
39Today we have covered
- Risk Management recap
- Risk Management under the microscope
- Tools and Techniques
- Case Study
40Thank you for participating