1. Risk Assessment Adviser
Dr Mike Rejman
Risk Assessment Adviser

2. Why do Accidents Happen?
Jacqui add notes

3. Why do Accidents Happen?
And be involved in high tech equipment.

4. How do Accidents Happen?
Organisation and processes
- Deficiencies
Prior conditions - basic causes
& contributory factors
“Unsafe” acts - active failures (SRK errors)
Multiple
Defences
These multiple defences take the form of barriers, controls and defences which stand between the patient and the hazard.
Patient Safety Incident

5. Understanding the Problem
~ 80% of accidents are attributable to human factors, at the individual level, the organisational level, or more commonly both
This is a conservative figure and is irrespective of domain
To manage this we need to identify and understand the risks (causes and contributory factors)
Without this we can’t put appropriate remedial action in place

6. Seven Steps to Patient Safety
Build a safety culture
2. Lead and support your staff
3. Integrate your risk management activity
4. Promote reporting
5. Involve patients and the public
6. Learn and share safety lessons
Implement solutions to prevent harm

7. Step 3 - Integrated Risk Management
All risk management functions and information:
patient safety,
health and safety,
complaints,
clinical litigation,
employment litigation,
financial and environmental risk
Training, management, analysis, assessment and investigations
Processes and decisions about risks into business and strategic plans

8. Risky Jobs

9. Risky Jobs

10. Risk Assessment by Donald Rumsfeld
As we know,
There are known knowns.
There are things we know we know.
We also know there are known unknowns.
That is to say
We know there are some things we know we do not know.
But there are also unknown unknowns -
The ones we don’t know we don’t know.

11. accidents serious incidents incidents near misses & hazards
The Accident Iceberg
accidents
serious incidents
incidents
near misses
& hazards 1 10 30
600

12. Prior Indicators of Risk
Challenger Space Shuttle
evidence of seals shrinking in cold temperatures, but political pressure to launch
Columbia Space Shuttle
long-standing problem with foam falling off (for 9 years)
even after Columbia disaster, a minority report noted at least 3 crucial issues not actioned
this endangered Discovery

13. Poor Design and Labelling

14. Poor Design and Labelling

15. Identifying Areas of Risk
Retrospective – learn lessons
Accidents and incidents,
Root Cause Analysis
Prospective – anticipate issues
Reporting systems, near misses, reported hazards
Prospective Risk Assessments, (proactive hazard assessment)

16. Some Risk Assessment Methods
HRA Techniques
HEART
Human Error Analysis and Reduction Technique
THERP
Technique for Human Error Prediction
SHERPA
Systematic Human Error Reduction and Prediction Approach
GEMS
Generic Error Modelling System
IDEAS
Influence Diagram Error Analysis System
(H)FMEA
(Healthcare) Failure Modes and Effects Analysis
HACCP
Hazard and Critical Control Points
HAZOPS
Hazard and Operability Studies
PRA
Probabilistic Risk Assessment
SWIFT
Structured ‘What If’ Technique

17. Risk Assessment Methods
There are a great many methods
Most were developed in safety-critical industries other than healthcare, only a few have been adapted to healthcare, with mixed success
Problems over
some quantitative, some qualitative
whether they can combine factors or only treat them independently,
issues over ‘number’ generation
few experimental comparisons, validation, or guidance
some very resource intensive
Which one to use?

18. Risk Assessment Methods
NPSA is developing two approaches to the issue –
(i) Patient Safety Research Fund – longer term research to identify the best methods for healthcare and adapt methods if necessary. Will take 2+ years to produce a toolbox
(ii) ‘Fast track’ pragmatic approach to produce guidance in the short-term

19. Risk Assessment’s Four Basics Questions
What could
go wrong?
How bad
could this
be ?
How often?
Is there a
need for
action,
if so what?
Patient safety risk assessments are careful examinations of systems to identify factors that could potentially cause or contribute to patient harm. They facilitate decisions on whether adequate precautions are being taken to ensure timely and safe provision of care or, if further measures are required to prevent or mitigate harm.
For each hazard identified it is important to decide whether it is significant and whether appropriate controls or contingencies are in place to ensure that the risk is effectively minimised

20. Lead to Four Management Options
Terminate
Treat
Tolerate
Transfer

21. SWIFT Structured ‘What IF’ checklisT
Good technique for considering both human and organisational factors, as well as equipment factors, that may affect safety
Structure
Identification driven by:
Question driven
What-if ………?
Checklist
Best done using a multi-professional group

22. Risk Assessment Flow Diagram Australian/New Zealand model
Establish the Context
Identify Risks
Evaluate Risks
Treat Risks
Accept Risks?
Likelihood
Consequences
Level of Risk
Analyse Risks
Communicate and Consult
Monitor and Review
yes no
Risk assessment is a “PROCESS”
Helps to determine if systems, facilities or activities are acceptable
Aid to decision making

23. Record Sheet

24. Risk Matrices Used for:
Qualitative assessment of the level of risk from an event
Commonly used in risk assessments
Found in many forms

25. Risk Matrix Risk Two dimensions Consequence
(Also commonly called impact or severity)
Likelihood
(Also commonly called frequency or probability)
How to use
Define for a risk:
Its consequence
Its likelihood
Read off the risk level
Risk
Frequency/Likelihood/Probability
Consequence / Severity / Impact

26. How to Use a Risk Matrix Identification of hazardous event/scenario
Determining the risk using a risk matrix
Assessment of the event’s/scenario’s consequence
Assessment of the event’s/scenario’s likelihood of occurrence
Determination of risk, (plotting scenarios on the risk matrix)
Risk evaluation and decision making

27. How to Use a Risk Matrix
Assessment of the event’s/scenario’s consequence
May be a range of possible outcomes
If possible chose outcome which is of regular concern
(Otherwise assess risk for different outcomes)

28. How to Use a Risk Matrix
Assessment of the event’s/scenario’s likelihood
Note that the likelihood is for the outcome being considered
Common error is to match event likelihood with worst case outcome which only happen in a minority of the event outcomes

29. How to Use a Risk Matrix Determination of risk
Plot scenario on the risk matrix

30. Risk Evaluation and Decision Making
The risk classes help drive risk mitigation decision making
Common approach:
Where the risk is assessed as:
“Low”
Evaluate as tolerable
No risk mitigation recommendations needed
“High”
Evaluate as intolerable
Risk reduction is required - aim to reduce medium or low
“Medium”
Evaluate as tolerable if ALARP demonstrated
Practical and cost effective recommendations to reduce risk needed

31. For Example - IT Systems
Introducing IT systems can greatly increase capacity AND help eradicate certain errors
BUT
Unless systems are carefully designed to take account of human factors, they can actually increase errors and even introduce new ones, with catastrophic consequences

32. New Technology in Airbus 320
‘Glass cockpit’ and ‘fly by wire’ state of the art technology
Multifunction displays with many ‘pages’ some of which are remarkably similar
Operator awareness issues - leading to the introduction of a new error - ‘mode error’
87 people died in a crash at Strasbourg

33. ‘New’ Error

34. Results from NPSA Funded Study on GP IT Systems (University of Nottingham)
Allergy alert may not be generated
Hazard alert generated every third prescription
Single keystroke to over-ride alert
No audit trail
Not all safety functionality activated (e.g. contra-indications)
Hazards generated by drop-down menus (wrong selection made – awareness)
GPs unsure of safety functionality on systems
Some think functionality is present when it isn’t (e.g. contra-indications)

35. Risk Assessment To ensure safe operation … Systems and Processes need:
To be well designed (human factors) and thoroughly risk assessed
To be more intuitive
To make wrong actions more difficult
To make correct actions easier (telling people to be more careful doesn’t work)
And it should be easier to discover error

36. Hospital at Night (HaN) Risk Assessment Guide
Presents an approach to risk assessing Hospital at Night solutions
Available on the NPSA web site
The aim of such an assessment is to help ensure HaN solutions are designed and implemented to provide safer patient care