L6. Understanding & Managing Clinical Risk.pdf

Understanding & Managing Clinical Risk Patient Safety Lecture no. 6 COLOR INDEX Main Text Important Male Slides Female Slides Dr’s Notes Extra  Recall terminologies: Hazards, Risk, litigation, incidence, accredi...

Understanding & Managing Clinical Risk Patient Safety Lecture no. 6 COLOR INDEX Main Text Important Male Slides Female Slides Dr’s Notes Extra  Recall terminologies: Hazards, Risk, litigation, incidence, accreditation. Recognize how we can learn from errors. Identify situational and personal factors that are associated with the increased risk of error. Participate in analyses of adverse event and practice strategies to reduce errors. Recognize how to apply risk-management principles in the workplace. Identify how to report risks / hazards in the workplace.. Knowledge requirements The activities used for gathering information about risk Fitness-to-practise requirements Personal accountability for managing clinical risk Performance requirements Keep accurate and complete health-care records Participate in meetings to discuss risk management and patient safety Respond appropriately to patients and families after an adverse event Respond appropriately to complaints Maintain their own health and well-being This lecture was presented by Prof. Hamza Abdulghani. For the required reading from Blackboard click here For the Video from Blackboard click here  Introduction ○ Hospitals are potentially dangerous places for patients as well as medical workers ○ It’s important to keep in mind that while there are a lot of potential hazards in hospitals ○ To avoid problems, hospitals and health organizations use a variety of methods to manage risk ○ Risk management is routine in most industries and has traditionally been associated with limiting litigation costs ○ Usually associated with patients taking legal action against a health professional or hospital Clinical risk management Hazard: is any activity, situation or, substance that potential to cause harm, including ill health, injury, loss of product and/or damage to patient and property. Blood borne Pathogens. Hazardous Chemicals. Stress. Risk: is the probability that harm (illness or injury) will actually occur. Risk Management: Organizational effort to identify, assess, control and evaluate the risk to reduce harm to patient, visitors and staff and protect the organization from financial loss. Purpose of Risk Management Creating and maintaining Identify and safe systems of Improve Support minimize the Protect the care, designed organizational regulatory, risks and organization to reduce and client accreditation liability resources adverse events safety compliance losses and improve human performance  Why clinical risk is relevant to patient safety? Clinical risk management specifically is concerned with improving the quality and safety of health-care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks. Process Used to Manage Clinical Risks The following simple four-step process is commonly used to manage clinical risks: Four-step process to clinical risk management Identify the risk: Use the following data as a sources for risk identification: ○ Adverse event reports. ○ Mortality and morbidities reports. ○ Patient complaints reports. Click here for Assess the frequency and severity of the risk: tables in slides ○ SAC (Severity Assessment Code) Score; It is a matrix scoring system based on: 1. Severity 2. Consequences for whom? 3. likelihood of risks. ○ These scores are multiplied to get a rating for the risk. Reduce or eliminate the risk Assess the costs saved by reducing the risk or the costs of not managing the risk  Gathering information about risk Incident monitoring The role of complaints in improving care Sentinel events Complaints and concerns where the individual is responsible Coronial Investigations Activities Commonly Used To Manage Clinical Risk The role of Fitness-to-practice Incident monitoring Sentinel events complaints in requirements improving care The key to an effective reporting system is for staff to routinely report incidents and near misses An incident As 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 Incident monitoring Refers to mechanisms for identifying, processing, analyzing and reporting incidents with a view to preventing their reoccurrence Click here for table in slides “Type of issues identified by incident monitoring”  Activities Commonly Used To Manage Clinical Risk The role of Fitness-to-practice Incident monitoring Sentinel events complaints in requirements improving care Is usually unexpected and involving a patient death or serious physical or psychological injury to a patient and including any process variation for which a recurrence would carry a significant chance of serious adverse outcome e.g. surgery on the wrong patient or body site, incompatible blood transfusion. Many health-care facilities have mandated the reporting of these types of events because of the significant risks associated with their repetition The role of Fitness-to-practice Incident monitoring Sentinel events complaints in requirements improving care Complaint Is defined as an expression of dissatisfaction by a patient, family member with the provided health care Benefits of complaints: ○ Complaints often highlight Help maintain trust in the profession problems that need addressing, such as poor communication or Encourage self-assessment suboptimal decision making. Protect the public ○ Communication problems are common causes of complaints, Reduce the frequency of litigation as are problems with treatment & diagnosis. Assist the maintenance of high standards  Activities Commonly Used To Manage Clinical Risk The role of Fitness-to-practice Incident monitoring Sentinel events complaints in requirements improving care 1 Accountability 2 Competency of healthcare professionals Are they practicing beyond their level of experience and skill? 3 Are they unwell, suffering from stress or illness Credentialing Registration (licensure) Accreditation Credentialing The process of assessing and conferring approval on a person’s suitability to provide specific consumer/patient care and treatment services, within defined limits, based on an individual’s license, education, training, experience, and competence. Registration (licensure)j Registration of health-care practitioners with a government authority, to protect the health and safety of the public through mechanisms designed to ensure that health practitioners are fit to practice. e.g. Saudi Commission for Health Specialties. ○ Proper registration/licensure is an important part of the credentialing and accreditation processes Accreditation Is a formal process to ensure delivery of safe, high-quality health care based on standards and processes devised and developed by health-care professionals for health-care services. ○ Accreditation Bodies: 1- National Accreditation Program: CBAHI 2- International Accreditation Program: Joint commission (US), Accreditation Canada (Canada) Role of fatigue and fitness to practise Professional Stress and mental health problems development and Work environment and organization self-assessment: Supervision Communication  Personal Strategies for Managing Risk and Reduce Errors Care for one’s self Prepare and plan (eat well, sleep well and Know your environment Know your task(s) (what if...) look after yourself) Build checks into Respond appropriately to Report any risks or Participate in meetings to your routine patients and families after hazards/incidents discuss risk management an adverse event in your workplace and patient safety Ask if you do not know, Practice the good Respond appropriately Request that a more documentation to complaints experienced person A referral or request for consultation: it is important to only include relevant and necessary information Keep accurate and complete health-care records Provide sufficient information Note any information relevant to the patient’s diagnosis or treatment and outcomes Document the date and time How to understand and manage clinical risks 1 2 3 Know when and how to ask for help Know how to Keep accurate and from an instructor, report known risks complete health-care supervisor or or hazards in the records appropriate senior workplace health-care professional 4 Participate in meetings that discuss risk management and patient safety 5 Respond appropriately to patients and families after an adverse event 6 Respond appropriately to complaints  Summary from slides Medical error is a complex issue, but error itself is an inevitable part of being human These tips are known to limit the potential errors caused by humans: ○ Avoid reliance on memory ○ Simplify process ○ Standardize common processes and procedures ○ Routinely use checklists ○ Decrease reliance on vigilance Learning from error can occur at both an individual level and an organizational level through incident reporting and analysis. Root cause analysis (RCA) is a highly structured systemic approach to incident analysis that is generally reserved for the most serious patient harm episodes. Health-care professionals are responsible for the treatment, care and clinical outcomes of their patients. Personal accountability is important, as any person in the chain might expose a patient to risk. One way for professionals to help prevent adverse events is to identify areas prone to errors. The proactive intervention of a systems approach for minimizing the opportunities for errors can prevent adverse events. Individuals can also work to maintain a safe clinical working environment by looking after their own health and responding appropriately to concerns from patients and colleagues. All health-care professionals should: ○ Be responsible for their patients – not just the seniors ○ Be personally accountable to prevent harm ○ Identify areas prone to errors ○ Work to maintain a safe clinical working environment by looking after their own health and responding appropriately to concerns from patients and colleagues  Weren’t explained by doctor and aren’t in the handout Tables from the slides  Questions from Doctor Note: Dr said these are the most asked questions in Exam. Anything written in grey wasn’t Explain the following terminologies: mentioned in slides or handout Is any activity, situation or, substance that potential to cause harm, including ill health, Hazards injury, loss of product and/or damage to patient and property. Risk Is the probability that harm (illness or injury) will actually occur. The failure of a planned action to achieve its intended outcome OR Error A deviation between what was actually done and what should have been done. Incidence Rate of occurrence or influence. The process of an individual or a business taking legal action against one or more Litigation parties to resolve a dispute. Accountability Being responsible for what you do. The act of recording a name or information on an official list OR Registration of health-care practitioners with a government authority, to protect the Registration health and safety of the public through mechanisms designed to ensure that health practitioners are fit to practice. Credential Anything that provides the basis for confidence, belief, credit, etc. Is a formal process to ensure delivery of safe, high- quality health care based on Accreditation standards and processes devised and developed by health-care professionals for health-care services. A harmful and negative outcome/s that happens when a patient has been provided with Adverse events medical care Is usually unexpected and involving a patient death or serious physical or Sentinel event psychological injury to a patient e.g. surgery on the wrong patient or body site, incompatible blood transfusion. Is defined as an expression of dissatisfaction by a patient, family member with the Complaint provided health care. What are the purposes of Risk Management? 1. Improve organizational and client safety 2. Identify and minimize the risks and liability losses 3. Protect the organization resources 4. Support regulatory, accreditation compliance 5. Creating and maintaining safe systems of care, designed to reduce adverse events and improve human performance Questions from Doctor Note: Dr said these are the most asked questions in Exam. Anything written in grey wasn’t mentioned in slides or handout What are the factors that are associated with the increased risk of error? Situations associated with an increased risk of error, Especially if combined with lack of supervision: 1. Unfamiliarity with the task 2. Inexperience 3. Shortage of time 4. Inadequate checking 5. Poor procedures 6. Poor human equipment interface What are the process used to Clinical Risks Management? 1. Identify the risk 2. Assess the frequency and severity of the risk 3. Reduce or eliminate the risk 4. Assess the costs saved by reducing the risk or the costs of not managing the risk. What are the activities commonly used for Clinical Risk management? 1. Incident monitoring 2. Sentinel events 3. Compliant 4. Fitness-to-practice requirements How can we learn from errors? 1. Collecting information of any event that have harmed or could’ve harmed by Incident reporting system. 2. Identifying the cause of error by root cause analysis. How can we analyze an adverse event to reduce errors? By applying Root cause analysis, which is a highly structured system approach to incident analysis. What are the risk-management principles? 1. Risk identification 2. Risk analysis 3. Risk control 4. Risk financing 5. Claims management How to report risks / hazards in the workplace? Hazards can be reported verbally, electronically or by filling out company specific forms that should be available at bulletin boards or other conspicuous places. Ask your supervisor, or health and safety committee or representative if there is a formal process for reporting hazards. Benefits of complaints? 1. Help maintain trust in the profession 2. Encourage self-assessment 3. Protect the public 4. Reduce the frequency of litigation 5. Assist the maintenance of high standards  MCQs Q1. Organizational effort to identify, assess, control and evaluate the risk to reduce harm to patient, visitors and staff and protect the organization from financial loss, Definition of? A. Error B. Risk management C. Hazard D. Risk Q2. Is the probability that harm ( illness or injury ) will actually occur is the definition of? A. Risk B. Hazard C. Risk management D. Error Q3. The hospital management noticed that there is an increased waiting time in the emergency department so they formed a committee to address this problem. What should the first action of the head of this committee be? C. Make a new system A. Gather data to know B. Form a quality D. Blame the reception for the emergency if the problem exists improvement team. team department Q4. Any activity, situation, substance that has a potential to cause harm , including ill health, injury, loss of the product to plant and property. This statement is a definition of which of the following? A. Risk B. Litigation costs C. Risk management D. Hazard Q5. The registration of health care practitioners with a government authority e.g. Saudi commission for health specialists is essential. Which of the following is an aim for this registration? A. To Ensure that B. To have a C. To reduce the D. To prevent sentinel health practitioners are distinguished staff in litigation costs events fit to practice health system Q6. “The process of assessing and conferring approval on a person's suitability to provide healthcare services, based on an individual’s license , education, training, experience and competence”. This statement is a definition of which of the following? A. Registration B. Accreditation C. Certification D. Credentialing A1. B A2. A A3. A A4. D A5. A A6. D Click here For Anki cards Made by Nazmi A Alqutub  Team Leaders Aroub Almahmoud Remaz Almahmoud Lama Almutairi Team Members Farah Abukhalaf Nazmi M Alqutub Aljoharah Alkhalifah Areej Alquraini Aleen Alkulyah Moath Alhudaif Aryam Almsari Rahaf Alshowihi Mohammed Alqutub Sarah Alshahrani Aishah Boureggah Raghad Alqhatani Sultan Albaqami Lama Alotaibi Lama Alrushid Sarah Alajaji Haya Alzeer Faris Alzahrani [email protected]