quality education for a healthier scotland the basics of risk management

Quality Education for a healthier Scotland

THE BASICS OF RISK MANAGEMENT


Housekeeping


STRUCTURE FOR THE DAY

• Risk Management recap

• Risk Management under the microscope

• Tools and Techniques

• Patient Safety Case Study


Risk Management recap


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!


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)


We all naturally manage risk every day…..


14 storey building


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.


Risk Management under the microscope


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


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?


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



Identify the risk

Evaluate the risk


priority)

Monitor and review


actions

Manage the Risk


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)



Identify the risk

Evaluate the risk


priority)

Monitor and review


actions

Manage the Risk


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.


NES Scoring Matrix


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.


We are all personally responsible for managing risks …


The Cumulative Act EffectThe SWISS CHEESE of Risk Management

James Reason 1990


Reasons for latent failure

Inadequate communication


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


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.


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


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)


Inadvertent Harm A Case Study


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.


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


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.


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


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.


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


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.


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.


Today we have covered

• Risk Management recap

• Risk Management under the microscope

• Tools and Techniques

• Case Study


Thank you for participating

Any questions?

quality education for a healthier scotland the basics of risk management

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