Risk Management Risk Management Awareness RaisingAwareness Raising

Dr.Ahmed Eltigani Elmahdi HussainDr.Ahmed Eltigani Elmahdi HussainConsultant Obstetrician&GynaecologistConsultant Obstetrician&Gynaecologist

Cavan General Hospital, IRELANDCavan General Hospital, IRELAND

Risk Management – Risk Management – who does it?who does it?

Nuclear IndustryNuclear Industry Aircraft IndustryAircraft Industry Chemical IndustryChemical Industry Oil and Gas IndustryOil and Gas Industry Transport SectorTransport Sector Finance SectorFinance Sector

Why do these industries Why do these industries prioritise Risk Management?prioritise Risk Management?

…… because they are all high risk industries because they are all high risk industries and any breach of safety has far reaching and any breach of safety has far reaching consequences in terms of:consequences in terms of:

– Their employeesTheir employees– The general publicThe general public– The environmentThe environment– Their reputationTheir reputation– Their survival and profitsTheir survival and profits

Risk Managent – DefinitionsRisk Managent – Definitions

…The culture, processes and structures that are …The culture, processes and structures that are directed towards the effective management ofdirected towards the effective management ofpotential opportunities and adverse events potential opportunities and adverse events

Source: AS/NZS 4360 :1999 R M StandardSource: AS/NZS 4360 :1999 R M Standard

…The process wherebye an organisation anticipates the…The process wherebye an organisation anticipates thepotential for injuries or losses and acts to avoid those potential for injuries or losses and acts to avoid those

injuries before and/or to ameliorate them after they occur injuries before and/or to ameliorate them after they occur

Source: R M in Health Care – Dr. G. RobertsSource: R M in Health Care – Dr. G. Roberts

RiskRisk Management - ProcessManagement - Process

…The systemic appllication of management policies, …The systemic appllication of management policies, procedures and practices to the task of establishingprocedures and practices to the task of establishing the context, identifying, analysing, evaluating, treating, the context, identifying, analysing, evaluating, treating,monitoring and communicating risk monitoring and communicating risk

Source: AS/NZS 4360 : 1999 R M tandard Source: AS/NZS 4360 : 1999 R M tandard

Is there any evidence that we Is there any evidence that we should do it in Healthcare?should do it in Healthcare?

• Beverley AllittBeverley Allitt• Bristol InquiryBristol Inquiry• Dr.ShipmanDr.Shipman• Blood Transfusion Services BoardBlood Transfusion Services Board• Organ RetentionOrgan Retention• McColgan Child Abuse InquiryMcColgan Child Abuse Inquiry• Dr. NearyDr. Neary

BRISTOL, ENGLANDBRISTOL, ENGLAND

In the period from 1991 to In the period from 1991 to 1995 between 30 and 35 1995 between 30 and 35 children under 1 died after children under 1 died after open-heart heart surgery open-heart heart surgery in the Bristol Royal in the Bristol Royal InfirmaryInfirmary

ENGLANDENGLAND Dr Shipman Family GP had Dr Shipman Family GP had

become the focus of Europe's become the focus of Europe's biggest ever murder biggest ever murder investigation investigation

Convicted of 15 murders, Convicted of 15 murders, suspected of killing more than suspected of killing more than 297 patients over 24 years. 297 patients over 24 years.

Health Care is a risky business Health Care is a risky business – – for patientsfor patients

Harvard Medical Practice Study, 1991Harvard Medical Practice Study, 1991 3.70% of hospital admissions lead to “adverse events”3.70% of hospital admissions lead to “adverse events” 1.85% of hospital admissions lead to avoidable “adverse events”1.85% of hospital admissions lead to avoidable “adverse events” 0.50% of hospital admissions lead to “adverse events” resulting in 0.50% of hospital admissions lead to “adverse events” resulting in

deathdeath corresponds to 120,000 avoidable deaths p.a. in USAcorresponds to 120,000 avoidable deaths p.a. in USA (corresponds to approx. 170,000 avoidable deaths p.a. in Europe)(corresponds to approx. 170,000 avoidable deaths p.a. in Europe)

Quality in Australian Healthcare Study, 1995Quality in Australian Healthcare Study, 1995 ““adverse event” rates of 14-16%adverse event” rates of 14-16% 98,000 avoidable deaths p.a.98,000 avoidable deaths p.a.

University College London, 1999University College London, 1999 UK 8-10%UK 8-10% Medical error kills >40,000 p.a. in the UK and is the third most likely Medical error kills >40,000 p.a. in the UK and is the third most likely

cause of death after cancer and heart disease (Vincent et al)cause of death after cancer and heart disease (Vincent et al)

Vincent et al, 2001Vincent et al, 2001 Retrospective review of 1.014 records in Retrospective review of 1.014 records in

London. London. 10.8% had an adverse effect (half preventable)10.8% had an adverse effect (half preventable)

Building a Safer NHS, 2001Building a Safer NHS, 2001 Study of 6,500 cases of adverse eventsStudy of 6,500 cases of adverse events 87 deaths87 deaths 345 serious injuries.345 serious injuries. Included hospital acquired infectionsIncluded hospital acquired infections

Health Care is a Risky Business Health Care is a Risky Business – for Patients– for Patients

How often do errors in care How often do errors in care occur?occur?

United Kingdom: 10-11%United Kingdom: 10-11% New Zealand: 10%New Zealand: 10% Denmark: 11%Denmark: 11% Australia (latest): 11%Australia (latest): 11%

Around one in ten hospitalised patients suffer an adverse event

Prescribing ErrorsPrescribing Errors In 2000, an estimated 1,200 people in England & In 2000, an estimated 1,200 people in England &

Wales died as a direct result of medication Wales died as a direct result of medication prescribedprescribed

(Audit Commission 2001(Audit Commission 2001))

Out of 193 claims, 19.3% were caused by Out of 193 claims, 19.3% were caused by prescribing errors.prescribing errors.

36 INCORRECT MEDICATION36 INCORRECT MEDICATION 24 CAUSED BY WRONG DOSE24 CAUSED BY WRONG DOSE

(MPS 2000)(MPS 2000)

Why is Risk Management an issue in Healthcare?

US - Medication errors cost 5-10% of healthcare budgets to remedy NHS - Excess bed occupancy due to medical error costs £750m pa NHS - Hospital acquired infections costs £1b pa NHS - Excess nursing absenteeism costs £200 - £400m pa NHS - 500k accidents to visitors and staff in hospitals costs £154m pa US - For every $1 cost of iatrogenic disease in the acute sector $1 is

incurred in the community 1 acute patient in 1000 will die of a hospital acquired infection ie 15% -

30% of which are preventable 1 acute patient in 100 will die of a pulmonary embolus ie 50% - 100%

of which are preventable

Why is Risk Management an issue in Healthcare? cont…

Health Care is a Risky Business – for staff

UK Health and Safety Commission, 1999:– “Average days lost per worker per annum due to work related

illness”– Armed Forces 0.30– Construction 2.18– Coal Mining 2.35– Nursing 2.74

– Average for all occupations 0.71

Why is Risk Management an issue in Healthcare? cont…

Health Care is a Risky Business - for staff– Sickness absence in the UK NHS costs £700m p.a.

Sickness absence rates of 5% compare to a national average of 3.7% representing £200m p.a. excess sickness absence for healthcare workers. (Williams, Mitchie, Pattani, 1998)

And it’s costly……wherever you work…….– There are 9000 to 9500 work related compensation

claims in the Irish courts each year (Byrne, 2001)

Why is Risk Management an issue in Healthcare? cont…

Healthcare is a stressful business….

– 46% of nurses feel “unsafe” at work and 17% perceive excess stress and insufficient support

– (Zurich Municipal/Glasgow Caledonian University, 1999)

– 30% of medical students suffer stress related disorders and 10% suffer mental illness (Wrate, 1999)

– 66% of doctors use alcohol to relieve stress, 40% feel negative affect toward patients (Firth-Cozens, 1999)

– public scrutiny and expectations of healthcare workers increases vulnerability to stress (James, 1999)

Clinical care

Theenvironmentof care

Financialresources

CLINICAL GOVERNANCE

ORGANISATIONALCONTROLS

FINANCIAL CONTROLS

Health & SafetyHuman ResourcesIntegrated CareDue Diligence

Risk StrategyQuality Reviews

Risk ReviewsClinical Audit

Practice DevelopmentsClaims ManagementEducation & training

Performance ManagementRe-engineering of Systems

Service Continuity Planning

Healthcare Risk Healthcare Risk ManagementManagement

The keys to making Risk The keys to making Risk Management workManagement work

ContextContext

CultureCulture

Risk Management SystemsRisk Management Systems

Establish Context

Identify Risks

Analyse Risks

Treat Risks

MON I TOR

Evaluate Risks

The Context – The Risk Management Process

AS/NZS 4360:1999 Risk Management Standard

COMMUNI CATE

Stop itAccident

Incident

Inve

stig

atio

n

Task

Person

Situation ??????

Discipline them

Past Approach: Person centred investigations

Why a systems approach?Why a systems approach?

Person approachPerson approach Who can we blame?Who can we blame? Doesn’t get to the bottom Doesn’t get to the bottom

of the problemof the problem Discourages reportingDiscourages reporting

System ApproachSystem Approach What can we learn?What can we learn? Looks at individuals as just one Looks at individuals as just one

component of eventcomponent of event Analyses all factors & how they Analyses all factors & how they

interactinteract Individuals are fallableIndividuals are fallable Errors are inevitableErrors are inevitable Not who made the error but why Not who made the error but why

did the defense systems fail?did the defense systems fail?

Defence Barriers

J. Reason 1994

Case Analysis Using Reason’s

Statistical failuresin defences

Organisational Accident Causation Model

SituationTask

Errors

Violations

Corporate Culture

Management decisions and organisational processes

Local climate

Error-producing conditions

Violation-producingconditions

Defence Barriers

Latent failures in defences

J. Reason 1994

Case Analysis Using Reason’s

Organisational Accident Causation Model

Statistical failuresin defences

Focus on process not Focus on process not individualindividual

““People and perfect processes make a People and perfect processes make a quality health service. Poor quality quality health service. Poor quality results from a badly designed and results from a badly designed and operated process, not from lazy or operated process, not from lazy or incompetent health care workers”incompetent health care workers”

Source: John Øvretviet, 1992 Health Service QualitySource: John Øvretviet, 1992 Health Service Quality

And Risk And Risk ManagementManagement involves….. involves…..

(AS/NZS 4360 and HSA “Workplace Health (AS/NZS 4360 and HSA “Workplace Health & Safety Management” )& Safety Management” )

IMPLEMENT

MONITOR & REVIEW PLAN

POLICY

IMPLEMENT

MONITOR & REVIEW PLAN

POLICY

Objectives

“Criteria”

Safety Statement

RM Policy

And Risk And Risk ManagementManagement involves…..involves…..

(AS/NZS 4360, Chapter 2)(AS/NZS 4360, Chapter 2)

Objectives of Risk ManagementObjectives of Risk Management

Minimise risks to quality of service and patient outcomesMinimise risks to quality of service and patient outcomes Ensure provision of a safe and effective serviceEnsure provision of a safe and effective service Confirm that service outcomes reflect planned intentionsConfirm that service outcomes reflect planned intentions Ensure that services are provided in an equitable and Ensure that services are provided in an equitable and

responsive fashionresponsive fashion Manage risk in partnership with patients, staff, the Manage risk in partnership with patients, staff, the

community and other providerscommunity and other providers Provide a safe and secure environment for staff and patientsProvide a safe and secure environment for staff and patients Ensure effective and efficient use of resourcesEnsure effective and efficient use of resources Seek to learn from mistakes and not to blameSeek to learn from mistakes and not to blame

Some Important DefinitionsSome Important Definitions

Near MissesNear Misses Actual occurrences which Actual occurrences which might have resulted in harmmight have resulted in harm

IncidentsIncidents Actual occurrences of harmActual occurrences of harm

RiskRisk The likelihood that The likelihood that those harmful those harmful consequences occurconsequences occur

HazardHazard Situation that might Situation that might result in harmful result in harmful consequencesconsequences

Examples:Examples: An unsheathed needle lying on the floor is a An unsheathed needle lying on the floor is a hazardhazard

The The riskrisk is that someone receives a needle stick injury is that someone receives a needle stick injury

If the needle is picked up by a member of staff who If the needle is picked up by a member of staff who places it, without injury, in a sharps box it was a places it, without injury, in a sharps box it was a near near missmiss

If someone picks it up and injures themselves before If someone picks it up and injures themselves before putting it in a sharps box this is an putting it in a sharps box this is an incidentincident

Incidents almost always Incidents almost always involve a systematic failureinvolve a systematic failure

Usually several factors Usually several factors have combinedhave combined

It is rare that one It is rare that one person alone is person alone is responsibleresponsible

Blame is more a Blame is more a matter of opinion than matter of opinion than a matter of facta matter of fact

Identifying Hazards and Identifying Hazards and RisksRisks

“Comprehensive identification using a

well-structured systematic process is critical”

It is important to identify both things that have happened (retrospective identification) and those that might (prospective identification)

Types of IdentificationTypes of IdentificationExternal Scrutiny External Scrutiny and Inspectionand Inspection

OccurrencesOccurrences Internal Internal AssessmentsAssessments

ProspectiveProspective RetrospectiveRetrospective ProspectiveProspectiveExample:Example: InsurersInsurers Internal audit Internal audit

functionfunction Accreditation bodies' Accreditation bodies'

reportsreports Specialist inspections Specialist inspections

(e.g. HSA, (e.g. HSA, Professional Bodies)Professional Bodies)

Example:Example: Incidents/near Incidents/near

miss reportingmiss reporting ClaimsClaims ComplaintsComplaints Sickness and Sickness and

absence absence recordsrecords

Staff turnoverStaff turnover Patient and Patient and staff staff

satisfaction satisfaction measuresmeasures

Example:Example: Specialist committeesSpecialist committees (Infection Control, Drugs (Infection Control, Drugs

& Therapeutics, & Therapeutics, Resuscitation, H&S, Resuscitation, H&S, Occupational Health)Occupational Health)

Clinical effectiveness and Clinical effectiveness and records reviewrecords review

Hazard reporting Hazard reporting Risk assessmentsRisk assessments Networking, use of Networking, use of

media reports and media reports and information from other information from other BoardsBoards

Assessing RisksAssessing Risks

“To avoid subjective bias, the best available information sources and

techniques should be used when analysing consequences and likelihood.”

Measuring RiskMeasuring Risk

Likelihood

Consequences

A

B

Rating the incidentRating the incident Done in conjunction with line Done in conjunction with line

managermanager Assists in managing risks through Assists in managing risks through

prioritisationprioritisation Rating of incident in respect ofRating of incident in respect of

Actual SeverityActual Severity Future LikelihoodFuture Likelihood

Extent of review determined by Extent of review determined by ratingrating

Rating the SeverityRating the Severity

* Based on national comparisons

Category

Severity

Quality & Prof.

Guidelines

Finance & Info.

Fear, disempowerment & conflict of interest

Safety(staff, patients/clients & NEHB population)

Reputation/ Community Expectation (& Equity)

Legal Requirements (and Equality)

Low Minor non-compliance 

< €5KMinor loss of info.

  Minor cuts/ bruises

Within unitLocal press < 1 day coverage

Minor out-of- court settlement. Minor legislative breach, no consequences

Minor Single failure to meet internal standards or follow protocol 

€5K - €25KClaim below excess

Verbal representation from minority groups. Concerns expressed by staff in 1 area/Dept.

  

Cuts/ bruises< 3 days absence< 3 days extended hospital stayEmotional distress

Regulator concernLocal press < 7 day of coverage

Civil actionImprovement Direction.

Moderate

Repeated failures to meet internal standards or follow protocols 

€25K - €1MLoss of or unauthorised access to confidential information

Sustained campaign by minority group(s). Consistent indication of fear/concern across 1 or more sites

 

Single system injury e.g. fracture, > 3 days absence, 3-8 days extended hospital stayHSA reportableSemi-permanent physical/emotional trauma

Regional/ National media < 3 day coverageDepartment notification/ executive action

Class action – no defenceCriminal prosecutionImprovement Notice

Severe Failure to meet national norms*/stds.Repeated failure to meet professional std. 

€1M - €5MLoss or corruption of key clinical information

Judicial review finds conflict of interest. Collapse of management relations across Hosp. Group. Increased sickness absence/resignations

>9 days extended hospital stayFatalityPermanent physical/emotional disability/trauma

National media > 3 day of coverageQuestions in the Dáil. Independent external enquiry

Criminal prosecution - no defence.Executive officer fined or imprisoned. Prohibition Notice.

Catastrophic

Gross failure to meet professional standards 

> €5M Multiple FatalitiesMultiple permanent physical/emotional injuries/trauma

Full Public Enquiry

Prohibition NoticeWidespread culture of bullying.

In accordance with AS/NZS 4360:1999 Risk Management Standard

Rating the LikelihoodRating the Likelihood RareRare – may occur only in exceptional – may occur only in exceptional

circumstancescircumstances

UnlikelyUnlikely – could occur at some time – could occur at some time

PossiblePossible – might occur at some time – might occur at some time

LikelyLikely – will probably occur in most – will probably occur in most circumstancescircumstances

Almost CertainAlmost Certain – is expected to occur in – is expected to occur in most circumstancesmost circumstances

Risk Rating MatrixRisk Rating Matrix

CatastrophicSevereModerateMinorLow

54321Rare

108642Unlikely

1512963Possible

20161284Likely

252015105Almost Certain

Lik

elih

ood

Severity

Recording the Outcome of the Recording the Outcome of the AssessmentAssessment

(The Risk Register)(The Risk Register)

Having completed the assessment of risk, the outcome is entered onto a risk register.

The risk register then becomes a summary of all known hazards/risks and is used to decide priorities for actions to control hazards/risks and to monitor the progress of those actions.

The Risk RegisterThe Risk RegisterRef. Risk Detail Likelihood Impact Score Owner Response 1 2 3 4 5

Risk Control OptionsRisk Control Options

Eliminate

Accept

Transfer

Reduce

Reducing RiskReducing Risk

Likelihood

Severity

Risk Prevention

Risk Mitigation

A unified but diverse teamA unified but diverse team Both at corporate and local level support will be Both at corporate and local level support will be

provided by a team of Advisorsprovided by a team of Advisors Their job is to Their job is to adviseadvise on risk issues, not manage them on risk issues, not manage them

for youfor you Due to the range of skills needed, the individuals will Due to the range of skills needed, the individuals will

have different specialisms. In particular:have different specialisms. In particular: The Risk Advisor will take a lead on clinical risk The Risk Advisor will take a lead on clinical risk

issuesissues The Health & Safety Advisor will take a lead on The Health & Safety Advisor will take a lead on

safety and legislative compliance issuessafety and legislative compliance issues The skills may be diverse, but the objectives of each The skills may be diverse, but the objectives of each

team member are the same [see RM Objectives]team member are the same [see RM Objectives]

Making it HappenMaking it Happen

“The responsibility, authority and the

inter-relationship of personnel who perform and verify work affecting risk management shall be

defined and documented”

IMPLEMENT

MONITOR PLAN

POLICY

Local Risk Assessments

Feedback on risks

Prioritise resources/responses

Training

Actions

Responsibility

Results of risk assessments

Incident Reporting

Claims

Complaints

Audits/Inspections

Sickness Absence

A Plan not a Strategy?

Important Risk Management IssuesImportant Risk Management Issues

MEDICAL RECORDS:MEDICAL RECORDS:

1.1. Documentation (admission, antenatal , portogram, OT, Documentation (admission, antenatal , portogram, OT, postnatal & gynae notes).postnatal & gynae notes).

2.2. Document the plan of management & Document the plan of management & WOMENWOMEN views. views.

3.3. SecuritySecurity

4.4. ConfidentialityConfidentiality

Explanation , Discussion & CounsellingExplanation , Discussion & Counselling

ConsentConsent

C0NCLUSIONC0NCLUSION

Blame cultureBlame culture

““We don’t make We don’t make mistakes” culturemistakes” culture

““So what” cultureSo what” culture

Silo or “tribal” cultureSilo or “tribal” culture

““not my business” culturenot my business” culture

Support don’t blameSupport don’t blame

We all make mistakesWe all make mistakes

Feedback & meaning Feedback & meaning

Team cultureTeam culture

It is everyone’s It is everyone’s businessbusiness