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Risk Assessment

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Title: Risk Assessment


1
Risk Assessment
Dr Mike Rejman Risk Assessment Adviser
2
Why do Accidents Happen?
3
Why do Accidents Happen?
4
How do Accidents Happen?
Organisation and processes - Deficiencies
Prior conditions - basic causes contributory
factors
Unsafe acts - active failures (SRK errors)
Multiple Defences
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 cant 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 dont know we dont know.

11
The Accident Iceberg
  • accidents
  • serious incidents
  • incidents
  • near misses
  • hazards



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 Assessments Four Basics Questions
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
  • 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
  • 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 events/scenarios consequence
  • Assessment of the events/scenarios 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 events/scenarios 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 events/scenarios 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 isnt
    (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 doesnt 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
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