Risk Management lecture RCOG

Definition:
Risk management: A logical and systematic method for identification, analysis
and control of actual and potential risks and their resource implications.
Clinical governance was introduced in 1998 by the Department of Health
with the explicit aim of improving the clinical care and safety of patients.
There are several strands in clinical governance; risk management is one of
the strands, which contributes to quality of care through a reduction in
errors and learning from these errors.
Risk: the probability of harm, from a hazard.
It also takes in to account the severity and extent of the harm. The hazard
can be physical, electrical, or from radiation but above all else clinical.
Risk management has two complementary components.
1. First is (prospective) the risk assessment, which is carried out before any
harm has happened
2. Second happens after the adverse event (retrospective) and is called
adverse clinical event reporting and analysis.
The various elements that should be considered during risk management include:
1. Hazard - something with potential to cause harm
2. Risk likelihood that the hazard is realised
3. Extent of risk the number of people affected
4. Control measures how to reduce the risk.
As stated earlier, when considering risk management one needs to consider what
is a hazard, how do we evaluate risks that might potentially happen from this
hazard, and how can these hazards be eliminated to minimise the risks. As the
hazards and risks can change potentially over time the assessment should also
be reviewed periodically.
Risk calculation:
Risk is measured in terms of likelihood and consequences. Risk is calculated by
multiplying the severity of harm with the likelihood of harm.
Existing level of risk =
Severity (measure of magnitude) X Likelihood (measure of frequency)
The most commonly accepted matrix, which describes severity of harm and the
likelihood of its frequency:

A risk assessment is done by measuring the risk of the potential severity of

impact (scale of 1-5; 1 minimum, 5 maximum, locally defined) and the likelihood
of occurrence (scale of 1-5; 1 low likelihood, 5 high likelihood of occurrence).
The multiplication of severity with the likelihood of occurrence gives the
composite risk index. The higher the figure of the risk, the less acceptable it
would be. A risk score of 20 or more is considered unacceptable.
Aims of risk assessment
The aims of risk management are to:
1. Identify hazards
3. Eliminate the hazards if possible
5. Monitor/review risks periodically.

2. Evaluate the risks

4. Minimise (control) the risks

Organisation With A Memory was a committee set up by the Chief Medical

Officer in 2000 and its main recommendation were:
1. To introduce a mandatory reporting system for adverse clinical events and
near misses.
2. To ensure lessons are learnt and implemented quickly.
3. The introduction of a confidential reporting system for staff.
4. Identification and addressing recurring adverse health care events.
The National Patient Safety Agency (NPSA) was set up in 2001 to promote
and improve patient safety, through analysing and learning from ACEs.Its role
includes:
1. Raising awareness of patient safety issues and to create a culture of
openness, eliminating the culture of blame.
2. To create a National Reporting and Learning System NRLS to capture
incidents affecting patient safety and to learn from them. A database was
designed and reports were published.
Risk identification and reporting
- In order to learn from adverse events it is important that all units have a
local mechanism where an incident report is generated every time an
adverse event has taken place.
- Every unit should have a trigger list to generate an incident form. This
should be linked to the trust reporting system, which in turn should feed
into NRLS (under NHS Special Health Authority).
- Incident reporting is now done electronically in most units. Many units in
the U.K. have an electronic incident form which is linked to the trust
governance team.
The events that lead to the generation of incident reports are called trigger
events and all units have established a list of triggers.
- Maternal triggers listed in this slide include:
1. Maternal death
2. Blood loss > 1500 ml from
hysterectomy
3. Return to theatre, readmission
4. Third/fourth degree perineal
tears
5. uterine rupture
6. Eclampsia
7. admission to ITU
8. VTE
9. Injury to the bowel, bladder or ureter during surgery.
- Common fetal/neonatal triggers:

1. Still birth/neonatal death

<7 at 5 minutes
3. Neonatal seizures
neonatal unit
5. Undiagnosed fetal anomaly
7. Born before arrival.

2. Cord pH < 7.1 venous, apgar

4.

Unexpected

admission

to

6. Birth trauma

The trigger list for gynaecology includes:

1. Injury to bladder, ureter, bowel or vessel.
2. Delayed or missed diagnosis (e.g. ectopic pregnancy)
3. Failed procedures (e.g. laparoscopy, hysteroscopy)
4. Unplanned blood transfusion
5. Unplanned admission to ITU
6. Retained swab or instrument
7. Omission of planned procedures (e.g. sterilisation)
8. Return to theatre or readmission within 1 month
9. Moderate/severe ovarian hyperstimulation.

Non clinical triggers

In addition to the clinical triggers there are non clinical triggers which can
adversely contribute to the patients quality of care;
1. missing case notes: at the top of the list.
2. Hospital acquired infection
3. Medication error
4. Unavailable or faulty equipment.

A serious incident definition

In 2010 the NPSA defined a serious incident as an incident that occurred during
NHS funded healthcare, resulting in:
- Death/severe harm to patients, staff or public
- A never event
- A scenario that prevents an organisations ability to continue to deliver
healthcare services
- Allegations or incidents of physical sexual assault or abuse
- Loss of confidence in the service, adverse media coverage or public
concern about healthcare or an organization
These serious incidents cover the whole institution, its staff, patients and the
public.
Never event definition
In addition to the serious events there are never events which according to the
NPSA should never happen. Never events are defined by the NPSA as Serious
largely preventable patient safety incidents that should not occur if available
preventative measures have been implemented by health care providers.
There are 25 never events of which two are specific to Obstetrics and
Gynaecology. These are:
1. maternal death due to post partum haemorrhage following elective
caesarean section
2. retention of a foreign object after a surgical procedure including a vaginal
birth.
Analysis of adverse clinical events:

Following on from the incident reporting the next step is the analysis, and
identification of all the factors, that contributed to the incident, and then making
recommendations for the future. As said before the process of risk management
is not only to identify the risks but learn from the events to prevent them
happening again.
There are several models available that help with the investigation. Most models
have the following steps:
1. Identification of adverse clinical event and decision to investigate
2. Organisation and data gathering
3. Determination of timeline of ACE
4. Identification of care delivery problems and contributory factors
5. Recommendations and action plan
6. Dissemination of lessons learnt through MDTs, newsletters, direct meetings
and risk management boards.
Further steps:
There are further steps that need to be taken, which include dissemination of the
learning points and escalation of the event nationally for trend analysis later. It is
also important to:
1. Report and record the event on local risk management systems (LRMS)
2. Ensure the event is recorded on STEIS (Strategic Executive Information
System)
3. Make sure the patient and family and relevant organisations are kept
informed
4. Implement the action plan
5. Lastly share the learning and keep the implementation of actions under
review.
Risk treatment and risk register
Risk treatment may include: Risk avoidance (elimination), risk reduction
(optimise, mitigate), risk sharing (outsource or insure) or retention (accept), all
may form the basis of action plan.
Risk register: As a part of the risk management strategy it is the responsibility of
each unit to maintain a register of risk, which maintains a record not only of risks
but also what actions were taken to minimise them. Risks above a set threshold
will need to be escalated to the trust and national risk register.
Summary
In summary, risk management is a tool that helps improve patient safety and
clinical care. Each unit should have a comprehensive strategy for its
implementation and periodic review.
All incidents should be identified and investigated in an open, no blame culture.
When incidents do happen it is usually a systems failure rather than an individual.
Lessons learnt should be disseminated across the team and wider as the case
might prevent a repeat of the incident.