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THE BASICS OF RISK MANAGEMENT

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Title: THE BASICS OF RISK MANAGEMENT


1
THE BASICS OF RISK MANAGEMENT
2
Housekeeping
3
STRUCTURE FOR THE DAY
  • Risk Management recap
  • Risk Management under the microscope
  • Tools and Techniques
  • Patient Safety Case Study

4
Risk Management recap
5
Risk 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!

6
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7
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)

8
We all naturally manage risk every day..
9
14 storey building
10
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11
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.

12
Risk Management under the microscope
13
Identifying 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)
14
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/Gove
    rnance requirements our Financial position our
    Operations / Service Delivery our Reputation or
    Credibility Health Safety?

15
Sources 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

16
Identifying 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)
17
Evaluate 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
18
Identifying 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)
19
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.

20
NES Scoring Matrix
21
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.

22
We are all personally responsible for managing
risks
23
The Cumulative Act EffectThe SWISS CHEESE of
Risk Management
James Reason 1990
24
Reasons for latent failure
25
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

26
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.

27
Problem 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

28
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 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)

29
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30
Inadvertent Harm A Case Study
31
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.

32
Timeline - 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
33
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.

34
Inadvertent 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?

35
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 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.

36
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
37
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
    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.

38
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.

39
Today we have covered
  • Risk Management recap
  • Risk Management under the microscope
  • Tools and Techniques
  • Case Study

40
Thank you for participating
  • Any questions?
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