Risk Management is the systematic identification of risks within an activity, system or process, and the implementation of actions that aim to 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.
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.
What are incidents and errors?
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.
What do we mean when we talk about incidents, errors and near misses?
Incidents – 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 that 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 taht could have resulted in an accident, but did not due to either chance or intervention.
Potential Risk – Anything that poses a threat to people or service provision.
RIDDOR – An incident reportable under the Reporting of Injuries, Diseases and Dangerous Occurances Regulations 1995.
All incidents, accidents and near misses must be recorded on Livewell Southwest’s Incident Reporting System (Safeguard) – most reports are now completed online.
All incidents must be reported verbally to the appropriate manager (ward manager, deputy locality manager, locality manager) as soon as possible after the incident occurs.
Serious Incidents Requiring Investigations (SIRI) resulting in death or serious injury should be immediately reported to the Risk Management Department, Director of Operations or On-Call DIrector (out-of-hours).
An incident will primarily be investigated by the service line manager to whom the incident was reported. The manager will undertake further investigation if necessary and record the results of the investigation on the electronic incident record.
Review and analysis of incidents and near-misses are necessary to identify the causes. Once the causes are identified action can be taken to minimise or prevent this incident happening again. Quality improvement tools, such as root cause analysis (RCA), are used to support investigations.
Risk assessment and risk register
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 organisation understand the range of risks that are inherent within the services 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.