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Risk Assessment Adviser

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Presentation on theme: "Risk Assessment Adviser"— Presentation transcript:

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

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