RISK MANAGEMENT

1324 words 6 pages
RISK MANAGEMENT
Clinical risk is an avoidable increase in the probability of harm occurring to a patient
Clinical Risk Management (CRM) is an approach to improving the quality and safety of healthcare by:



placing special emphasis on identifying circumstances that put patients at risk of harm acting to prevent or control those risks

CRM helps the hospital: to maintain and improve quality of services improve patient safety reduce frequency of litigation help maintain trust in profession prevent staff lose
Medical Error
It is the failure of a planned action to be completed as intended (i.e. error of execution e.g. error of drug dose calculation) or the use of wrong plan to achieve an aim (I.e. error of planning e.g. wrong lab result
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Assessing frequency and severity of the risk
 Use of risk rating scale
 Risk level = likelihood of risk occurrence x severity of the consequence

3.

Reduce or eliminate the risk
 Prioritize the risk
 Analyse the cause of the risk i.e. root cause analysis
 Find solutions

4.

Assess the cost saved by reducing the risk or cost if the risk eventuates
 Implement the solution
 Monitor the result

ROOT CAUSE ANALYSIS
RCA is a retrospective system approach to get to the true root cause of our process problem. It is used so we can correct or eliminate the cause, and prevent the problem from recurring. It tries to identify gaps which made an incident to happen. RCA looks back in time at an event and asks “What happened?
Why did it happen? How did it happen?”
Root Cause is the fundamental breakdown or failure of a process which, when resolved, prevents a recurrence of the problem.
Steps of RCA
1.

Establish an accurate chronological depiction of the series of events preceding the adverse event or near miss
 Include only those events that are crucial to understanding what transpired

2.

Ask “Why?”
 Write down the problem and start asking why it happened
 Repeat asking why until there is an agreement from the team that the root cause has been identified
 Usually takes about 3-5 whys

3.

Cause effect analysis
 Using ‘fishbone diagram’

4.

Identify the root cause

After identifying start with cause and ask “How?” using tree diagram to get solutions

5.

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