Risk Management

What is Risk Management?

Risk Management is the systematic identification of risks within an activity, system or process, and the implementation of actions which will minimise harm arising from these risks. One of the most important aspects of risk management is learning from mistakes or near misses in order to reduce the risk of them recurring.

Risk Management and Patient Safety

‘Freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.’ Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000:211.

Patient safety is concerned with finding out ‘why it happened’ by encouraging staff and patients to report and review incidents. An understanding of why something has happened gives you an opportunity to change the way care is delivered. Therefore patient safety involves minimising the risk of error to patients.

The potential for error presents a constant challenge in the safe delivery of health services. When things go wrong, or are narrowly avoided, there is an opportunity for patients, teams and organisations to identify why it happened and act to improve patient safety.

Incident

Any untoward or unexpected event which interferes with the orderly progress of day to day activity and which results in, or could have resulted in:

Harm to an individual or individuals.
Damage or loss to property including buildings, equipment, vehicles and materials.
An unintended or unexpected event that led to patient/staff harm, including death, disability, injury, disease or suffering

Clinical Incident

An incident which interferes with the treatment of a patient and results in, or could have resulted in inappropriate or inadequate clinical care, an injury or serious injury.

Near Miss

Any event, circumstance or situation that could have resulted in an incident, but did not due to either chance or intervention.

Potential Risk

Anything that poses a threat to people or service provision.

An incident reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995

The Department of Health’s report ‘Building a Safer NHS’ (April 2001) highlighted the importance of not only learning from incidents which already happened but also that it is essential to identify factors that could affect patient safety and take steps to reduce these risks.

Risk assessment is the process that helps the trust understand the range of risks that are inherent within the service we provide, the level of ability to control these risks, their likelihood of occurrence and the potential impact they may have on patients, staff and the service as a whole.

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Risk Management

What is Risk Management?

Risk Management and Patient Safety

Incident

Clinical Incident

Near Miss

Potential Risk

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Risk Management

What is Risk Management?

Risk Management and Patient Safety

What are incidents and errors?

What do we mean when we talk about incidents, errors and near-misses?

Incident

Clinical Incident

Near Miss

Potential Risk

RIDDOR reportable incident

Risk assessment and risk register

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