10 Questions
What is the primary goal of incident monitoring?
To identify and prevent reoccurrence of incidents
What is a sentinel event?
An unexpected event involving patient death or serious physical or psychological injury
What is the definition of an incident in the context of clinical risk management?
An event or circumstance that could have or did lead to unintended and/or unnecessary harm to a person and/or a complaint, loss or damage
Why is it important for staff to report incidents and near misses?
To identify and prevent reoccurrence of incidents
What is the role of complaints in improving care?
To identify areas for improvement in healthcare services
What is the purpose of categorizing risks in clinical risk management?
To prioritize risks and allocate resources effectively
What is an example of a sentinel event?
Surgery on the wrong patient or body site
What is the purpose of reporting sentinel events?
To identify and prevent reoccurrence of events
What is a common feature of sentinel events?
They are unexpected and involve patient death or serious physical or psychological injury
Why is incident monitoring important in clinical risk management?
To identify and prevent reoccurrence of incidents
Study Notes
Risk Management in Healthcare
- Failing to manage risks can lead to crisis situations with harmful consequences for patient safety and public health.
Clinical Risk Management
- Hazard: any activity, situation, or substance that has the potential to cause harm, including ill health, injury, loss of product, and/or damage to plant and property.
- Examples of hazards: blood-borne pathogens, hazardous chemicals, stress.
- Risk: the probability that harm (illness or injury) will actually occur.
Purpose of Risk Management
- Improve organizational and client safety.
- Identify and minimize risks and liability losses.
- Protect organizational resources.
- Support regulatory and accreditation compliance.
- Create and maintain safe systems of care to reduce adverse events and improve human performance.
Process of Managing Clinical Risks
- Identify the risk.
- Assess the frequency and severity of the risk.
- Reduce or eliminate the risk.
- Assess the costs saved by reducing or managing the risk.
Identifying Risks
- Use data sources such as:
- Adverse event reports.
- Mortality and morbidities reports.
- Patient complaints reports.
Assessing Risks
- Use the Severity Assessment Code (SAC) Score: a matrix scoring system that gives numerical scores to the severity and likelihood of risks, and multiplies them to get a rating for the risk.
Clinical Consequence Rating
- 1: Extreme - severe injury or illness, resulting in permanent injury or disability or ill health to one or more persons.
- 2: Major - major or multiple injuries, resulting in temporary disability or ill health to one or more persons.
- 3: Moderate - injury or illness requiring medical or psychological treatment to one or more people.
- 4: Minor - minor injury, first aid treatment required, no lasting impact.
- 5: Insignificant - no treatment required.
Managing Clinical Risks
- Incident monitoring: mechanisms for identifying, processing, analyzing, and reporting incidents to prevent their reoccurrence.
- Sentinel events: unexpected events involving patient death or serious physical or psychological injury.
- Fitness-to-practice requirements: ensuring healthcare professionals have the necessary skills and competencies to provide safe care.
- Patient complaints: expressions of dissatisfaction with healthcare provision, used to improve care.
Learn about risk management in healthcare, including clinical risk management, hazards, and the importance of mitigation to ensure patient safety and public health.
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