INTRODUCTION TO RISK MANAGEMENT IN HEALTHCARE - PowerPoint PPT Presentation

INTRODUCTION TO RISK MANAGEMENT IN HEALTHCARE

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INTRODUCTION TO RISK MANAGEMENT IN HEALTHCARE Stuart Emslie What is risk? Risk management process AS/NZS 4360:2004 - Risk management Risk perception Risk perception . – PowerPoint PPT presentation

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Title: INTRODUCTION TO RISK MANAGEMENT IN HEALTHCARE

• FMEA
• FMECA
• HFMEATM
• SFMEA
• Failure Mode and Effect Analysis
• Failure Modes and Effects Analysis
• Failure Modes, Effects and Criticality Analysis

• first developed by the U.S. military in 1949 to
  evaluate the reliability of systems and equipment
  and the consequences of their failure.
• 1960s NASA and US firms
• 1990s US healthcare
• Product design
• Process design or re-engineering
• Proactive hazard/risk analysis

1. Select a process (topic)
2. Assemble your team
3. Describe the process steps

1. Select a process (topic)
2. Assemble your team
3. Describe the process steps
4. Identify the ways in which each process step can
   fail (failure modes e.g. drug
   maladministration performing wrong site surgery
   clinical mis-diagnosis etc.)
5. Identify the root cause(s) of failure (Why?)
6. Identify the most likely effect(s) (i.e.
   consequence of failure) of each identified
   failure mode
7. Assess risk associated with each failure mode
   (consequence and likelihood from risk matrix)
8. Identify additional controls required (actions to
   effect improvement)
9. Implement additional controls
10. Test process improvements

• Dr Joseph Lui
• CCC (Risk Management), KWC

• Premature discharge of patients leading to death
  or poor outcome due to bed shortage

• Delay or missed diagnosis/treatment resulting in
  increased mortality morbidity
• Risk of harming patients associated with invasive
  procedures
• Long waiting lists resulting in increased
  morbidity complaints
• Medication error
• Harm to staff due to violent patients

• Risk associated with equipment failure
• Risk associated with inadequate supervision of
  trainees
• Risk of giving the wrong drug to patient due to
  mislabeling
• Risk of overdosing patient due to malfunctioning
  of PCA
• Risk of making unsound judgement after long hours
  of duty

• Risk of malfunctioning of resuscitation equipment
  due to lack of maintenance
• Risk of improper use of Level I rapid transfuser
  in emergency due to inadequate training
• Risk of staff injury and equipment failure due to
  cables power cords lying on the OT floor
• Risk of injury to staff
• Bumping of head against theatre light
• Slip fall after mopping of OR

• Risk associated with missing specimen or X ray
  films
• Patient Identification
• Medication, Xray Path reports
• Miss labeling of specimen
• Risk associated with Equipment Maintenance
  Validation
• Risk associated with Manual handling
• Risk associated with chemical waste handling
• Risk associated with understaffing

1. Infection control
2. OSH
3. Medication error
4. Resuscitation
5. Transfer of patients
6. Documentation of medical records, including
   consent
7. Patient identification (during consultation,
   blood sampling, operation for investigations)
8. Wrong site surgery
9. Proper use of infusion pumps
10. Medico-legal risk (open disclosure)

• SARS and review reports
• Resources availability
• Funding
• Beds
• Staffing
• People capacity
• Service expansion/demand
• New technology
• Evolution of cluster management

1. Risk is inherently negative, implying the
   possibility of adverse consequences. Describe the
   potential consequences if the risk were to
   materialise
2. Describe the causal factors that could make the
   risk materialise
3. Ensure that the context of the risk is clear,
   e.g. is the risk target well defined (e.g.
   staff, patient, department, hospital, etc.) and
   is the nature of the risk clear (e.g.
   financial, safety, physical loss, perception,
   etc.)

• Risk to patients due to errors and unsafe
  clinical practice caused by reduced skill base
  and competence of junior and middle grade medical
  staff
• Needlestick injury
• OSH
• Reduced staff retention and increased sickness
  absence due to reduction in morale caused by
  increased workload, pressure and stress to
  achieve targets
• Inadequate patient transfer
• Budget overrun and financial deficit due to cost
  of introducing new technologies/medicines as
  required by NICE guidance
• Medication error
• Loss of use of ICU due to fire

1. Think about yourself and your colleagues list 3
   issues or concerns you have at work.
2. Now think about patients list 3 issues or
   concerns you might have in relation to the safety
   or quality of care provided to patients in your
   department, hospital etc.
3. Finally, think about your organisation list 3
   issues or concerns..