claire bűchner259745,en.pdf• victoria climbie • dr shipman • sperrin & lakeland trust...
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Managing the
Environment - Risk
Claire Bűchner
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Aim of this session
To promote and highlight the
nurse‟s responsibility for
managing risk
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Objectives At the end of the session students will be able
to: -
• Understand their role in managing risk
• Understand how risk management affects nursing care
• Outline current developments including policy regarding risk management
• Understand the role of the nurse within the management structure with regard to quality assurance, resource and risk management
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Background • The New NHS – Modern and Dependable
(DOH,1998)
• A First Class Service (DOH,1998)
• NHS Plan (DOH,2000)
• An Organisation with a Memory (DOH,2000)
• Building a Safer NHS for Patients
(DOH,2001)
• Supporting Safer Services (DHSSPS,2006)
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Why Risk Management is
Important
• To enhance quality of treatment and care services
• Provide safer environment for staff
• Improve public confidence and Trust‟s reputation
• Learn from what has gone wrong
– Reduce costs of replacement, repair, and claims
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An organisation which reports many
incidents does not necessarily mean that
this organisation is unsafe but rather the
converse may be true i.e the organisation
may have achieved more in terms of
supporting an open and learning culture
Supporting Safer Services DHSSPS June 2006
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Definition: (AS/NZS 4360: 1999)
Risk Management (The Standard)
Risk – the chance of something happening that will have an impact on objectives. It is measured in terms of consequences and likelihood
Risk Management – the culture, processes and structures that are directed towards the effective management of potential opportunities and adverse effects
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Hazard and Risk
• A HAZARD is something with the potential to
cause harm
• A RISK is the likelihood of the hazard being
realised
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Incidents and Near Misses Incident Any event that has given or may give rise
to actual or possible personal injury, to patient/client dissatisfaction or to
property loss or damage
Near Miss Any event that did not lead to personal harm but could have, an occurrence which but for luck or good management, would in all probability have become a fully blown incident
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Example • An unsheathed needle lying on the floor is a hazard
• The risk is that someone receives a needle stick injury
• If the needle is picked up by a member of staff who places it, without injury, in a sharps box it was a near miss
• If someone picks it up and injures themselves before putting it in a sharps box this is an incident
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Risk Management Cycle/Process
• Risk Identification
• Risk Analysis
• Evaluating the Risks
• Treat Risks
• Monitor and Review
• Communicate and consultation
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Clinical Risk
Assessment
Triggers
Clinical
Audit
Incidents
Complaints
Litigation
Medicines &
Blood
Products
Equipment
Consent &
Patient
Information
Communication &
Confidentiality
Records:
Documentation
Record Keeping
Standards:
Practices
Protocols
Procedures
Policies
Staff:
Induction
Competence
Job Description
Training
Environment
Clinical Care:
Assessment
Planning
Delivery
Evaluation
Clinical
Supervisor
Methods of Identifying Clinical Hazards
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What do I do if I Identify a
Hazard?
• Check if a risk assessment is already
completed –if not advise line manager
• Complete an incident form
• If the hazard involves or potentially
involves a patient or client ensure it is
recorded in the care plan
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How is Risk
Rated/Analysed?
Risk is measured in terms of
likelihood and impact (severity
of harm)
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Likelihood
IMPACT (Consequence/Severity)
Insignificant
(1)
Minor
(2)
Moderate
(3)
Major
(4)
Catastrophic
(5)
Almost
certain (5) H H E E E
Likely (4) M H H E E
Possible (3) L M H E E
Unlikely (2) L L M H E
Rare (1) L L M H H
Risk Assessment Matrix
Low
Moderate
Extreme
Manage by routine procedure
Management responsibility must be specified
Senior management attention needed
Immediate action required
High
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Risk Treatment Options
ELIMINATE
or AVOID
ACCEPT
TRANSFER
REDUCE
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Risk picture
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Health and Social Care
Policy on Incident Reporting
Health and Social Care Trusts are concerned with preventing adverse incidents occurring,
not with blame or liability
N.B Professional and Statutory
obligations
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Health and Social Care Policy on
Incident Reporting
• The Risk Management system is facilitated by effective incident recording, which must be a high priority
• A supportive, open and learning culture that encourages staff to report mistakes, incidents and near misses through the appropriate channels underpins this
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Cost of Incidents
• £2 billion alone in costs for additional hospital stays for patients who have suffered harm
• 10% of admissions suffer harm to some degree
DOH An organisation with a memory 2000
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Why Report Incidents and Near
Misses?
• Can help protect staff and the Trust
• Professional accountability
• One of the most important ways you can tell
your organisation about risks and help
improve services for patients, your colleagues
and yourselves
• Lessons can be learned and trends assessed
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Why Report Incidents and
Near Misses? • Health and Safety Legislation, including RIDDOR
• Onward reporting to external bodies e.g. DHSSPS,
EHSSB, RQIA
• Incidents involving equipment may require to be reported to NIAIC, possibly for regional action
• Trust policy
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Reporting Incidents
• Who ? - Any member of staff can report
• Where ? - On an incident form
• When? - As soon as possible after the event
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Examples of Potentially
High/Extreme Clinical Risk
Incidents • Incorrect patient identity
• Inadequate documentation
• Failure to observe adequately
• Failure to Refer
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Evidence of Communication
• Report and record anything you did or
anything that could have caused risk to
patients or clients
• Don‟t be tempted to „keep it quiet‟ because a
trusted colleague is involved N.B Duty of care
to patients and clients
• Communicate fully (written and verbally) to
other health professionals regarding
patients‟/clients‟ care on a day to day basis
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Familiarise Yourself With…
• The Risk Management Strategy
• Risk Management Policies and Procedures
• Staff information leaflets
…in the area you are working
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Words of Advice…
• Do not accept that incidents/accidents
are inevitable
• Be proactive rather than reactive to aim
to prevent harm from incidents
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PRIMUM NON NOCERE Florence Nightingale 1863
Most importantly cause no harm
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Suggested Further Reading…
• National Patient Safety Agency Website www.npsa.nhs.uk/
• DHSSPS Paper: Supporting Safer Services 2006
• DOH Organisation with a Memory 2000
• DHSSPS Paper: Safety First: A Framework for Sustainable
Improvement in the HPSS 2006
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Quality
“Quality is doing the right thing for the right
person at the right time and getting it right first
time, every time” Crosby 1990
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Food for Thought
YET!
30-40% of patients do not receive care in line
with current scientific evidence and,
10% of hospital admissions are due to adverse
incidents Safer Patient Initiative 2004
“Believe it or not, quality is free” Crosby 1990
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Quality
Know your role
Deliver your role
Behaviour within
your role
Role & behaviour
assessment
Improve/Implement
Change
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Know Your Job/Role
Understand your job/role Recognise potential risk Awareness of relevant policies/
procedures/guidance
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QUALITY
RISK
Governance…
…meeting the needs of patients, clients, visitors and
colleagues in the safest possible way.
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What happens when we get it wrong?
• Bristol Heart Surgery
• Kent & Canterbury
• Victoria Climbie • Dr Shipman
• Sperrin & Lakeland Trust Review Report(s)
• Endoscope Review
• Janine Murtagh
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For the Organisation
For the Patients/Clients
Impressions…
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Behaviour
! The words we speak
! Our intonation
! Our non-verbal gestures
Eye contact
Body language
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Ensuring A Good Quality Service
Quality Improvement Initiatives…
• Audit
• User consultation
• Setting standards
• Best practice
• Complaints, comments and suggestions