- Clinical risk management (CRM)
- Clinical risk is the potential for an unwanted outcome
- Patient safety incident (critical incident) - an incident which did, or could have, lead to harm
- Common causes
- Lack of policy or guideline
- Deficient working practices
- Poorly defined responsibility
- Inadequate training or supervision
- 5 stages
- Risk awareness
- Hospitals are complex and this brings risk
- Risk identification
- Process for identifying specific risks
- Risk assessment
- Assessment of the magnitude of the risk and how likely it is to occur
- Risk management
- Plans to minimise the risks to tolerable levels
- Risk reassessment
- Risks reviewed with the aim of developing safer systems
- Risk identification
- Retrospectively
- Critical incidents
- Feeds into NPSA who issue patient safety alerts
- Complaints and claims
- Retrospective case note review
- Root cause analysis
- Data collection
- Presentation of information so problems can be identified
- Root cause identification
- Recommendations and implementation
- Prospectively
- Planning departments
- Staff planning
- Equipment
- Staff training
- Re-evaluation
- Risks should be reviewed regularly
- Ensure remain accurate
- Ensure no new risks have been introduced
- Risk management
- Physical barriers (eg locked drug cupboards)
- Incomplete barriers (eg drug labelling)
- Policies and guidelines
- Education & training
- Severity and frequency are then put into a matrix and assigned an overall risk rating or numerical value
- Risk assessment and analysis
- Risk assessment and analysis. A commonly used scale for outcome severity is:
- None, no adverse clinical outcome
- Minor short term injury taking up to 1/12 to resolve
- Moderate injury that may take up to 1yr to resolve
- Major, causing permanent disability
- Catastrophic, resulting in death
- Frequency of occurrence
- Almost certain to happen and to occur repeatedly
- Likely (expected to occur)
- Possible (not expected to occur)
- Unlikely (occurs in large organisations on less than annual basis)
- Rare (an event a clinician is unlikely to see in their career)
- CEACCP
Link:ceaccp.oxfordjournals.org/content/6/6/240.full.pdf