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Aim of programme to apply the principles of risk management to
practical situations and relate these to personal experiences
to improve the quality of care by implementing initiatives to remedy deficiencies in the service provided.
Harvard Medical Practice StudyHarvard Medical Practice Study New England Journal of Medicine 1991New England Journal of Medicine 1991
3.7% patients suffered an 3.7% patients suffered an adverse eventadverse event
Of these 13% Of these 13% dieddied
58% events related to system 58% events related to system errorserrors
Summary of New Complaints Procedure Summary of New Complaints Procedure ((1998, 9/12 period)1998, 9/12 period) MDU experienceMDU experience
Failure or delay in diagnosis most common Failure or delay in diagnosis most common reason (28%)reason (28%)
24% of complaints made after bereavement24% of complaints made after bereavement
Non-clinical issues accounted for 34% of Non-clinical issues accounted for 34% of complaintscomplaints
10% of complaints related to attitude10% of complaints related to attitude
93% settled at L.R.93% settled at L.R.
MDU Settled Claims Against MDU Settled Claims Against UK GPsUK GPs
Failure to diagnose Failure to diagnose - 51% - 51% Medication error Medication error - 26% - 26% Pregnancy including labour - 13%Pregnancy including labour - 13% Minor surgical procedure - 7%Minor surgical procedure - 7% Other Other - -
3%3%
MDU Claims SettledMDU Claims Settled
Quality of medical care - Quality of medical care - 7%7%
Medical record issues -Medical record issues - 60%60%
System failures-System failures- 33%33%
MDU complaints study 1999 33% complaints were due to failures in
systems, procedures and communication e.g. rudeness/attitude staff or doctor administration problems prescription problems communication
Clinical Governance
Clinical risk management
Complaints procedures
Adverse incident reporting
Clinical audit
Evidence- based practice
Whistle blowing
Performance review
RISK MANAGEMENT
A careful examination of what A careful examination of what
1.1. could cause harmcould cause harm
2.2. its significance and its significance and
3.3. what precautions are needed to eliminate the what precautions are needed to eliminate the
risk or reduce it to an acceptable levelrisk or reduce it to an acceptable level
Risk Management Benefits for patients
– improved quality of care and service– enhanced patient safety– confidence in the service
for health care professionals– protection of confidence and reputation– quality procedures and staff involvement– decreased numbers of complaints and
claims
The four principles of risk management
1. Identify the risks – what’s likely to go wrong?
2. Assess the risk – what are the chances of it going wrong, what could happen, does it matter?
3. Reduce/eliminate the risk – what can you do about it
4. Cost the risk – what are the costs of getting it right v. the cost of getting it wrong?
Risk Management Techniques
Complaint handling
Risk assessment
Staff awareness/training
Protocol and guidelines monitoring
Good medical records
Adverse incident reporting
Risk Areas
Staff - especially locums
Organisation adequate staffing regular guideline review
Communication
Consent
Record keeping
Clip 2 – Morning Surgery
Identified Risks
Breaches of confidentiality – front desk/reception area etc.Health and safety issue.Lack of systems.Phone call interruptions.Verbal requirements regarding nurse visit.Inappropriate roll/responsibilities of receptionist.
What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?
Clip 3 – Test Result / Minor Surgery
Identified Risks
Dealing with smear results.Aseptic techniques.Lack of chaperones.Unreasonable patient request.Lack of informed consent.Disposal of clinical waste/needles.
What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?
Clip 4 – Home Visit
Identified Risks
Examination.Response to collapsed patient.Communication regarding hospital admission.Communication with mother.Dealing with request for repeat prescription.Dealing with aggressive patient.
What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?
Aims of Assessment
Improve patient care
Ensure safe standards of practice
Ensure patient/staff safety and well being
Decrease the number of complaints and claims
Lessen the stress associated with litigation
The MDU’s risk management pack
Part one - Communication
How to use it
Each part contains:
Case history examples Checklist Reference sections Action plan Score/evaluation sheet
How to complete
Team approach set aside protected time read questions and reference section undertake the review (‘yes’ or ‘no’
answers) consider action needed complete action plan complete the anonymised answer sheet return sheet to PCG offices
Scoring system
Yes - undertaking the activity No - area needs review Score 3 = essential Score 2 = important Score 1 = good practice