Lecture 15 - risk management

Question 1

what is risk management?

Answer 1

Risk management is the systematic identification, assessment and reduction of risks to patients, staff and the organisation.

Question 2

wha are the focus areas of the medicines governance team?

Answer 2

quality improvement

learning from near misses and errors

education and training

risk assessment and management

policy development

Question 3

Medication Safety & Harm from Medicines in NHSGGC

Answer 3

In 2020:
3781 medication incidentsreported
651 were moderate, major or extreme*

Question 4

what are high risk medicines?

Answer 4

‘High risk medicines are defined as medicines that have a high risk of causing injury or harm if they are misused or used in error. Error rates with these medications are not necessarily higher than with any other medicines, but when problems occur, the consequences can be more significant.

Question 5

what are examples of high risk medicines?

Answer 5

Warfarin
Heparin
Insulin
Methotrexate
Vancomycin
Gentamicin
Opiates
Sedatives
Penicillins
Paracetamol

Question 6

what are proactive risk management strategies

Answer 6

Identifying Risks:
Local, regional or national bodies / healthcare professionals
Local risk assessment / identification
Current literature
The media
Patients, patient interest groups
Development of a multidisciplinary, strategic, co-ordinated approach to risk management of medicines

Question 7

what are risk management strategies for injectable medicines ?

Answer 7

Development of over 150 IV Drug Monographs - risk assessment of all injectable medicines

Purchasing ready-to-administer products

Introduction of dose-banded cytotoxics

Controls over cytotoxic intrathecals

CD requirements and controls for concentrated potassium

Antibiotic IV to Oral Switch Therapy Guideline

Question 8

how can we ensure reactive risk management ?

Answer 8

Report and investigate incident

Roll-out of Datix web-based incident reporting

‘Significant Adverse Even Review Policy’ & ‘Fair Blame’ Culture

Implement risk reduction strategies
more complicated processes have higher chance of failure

Review incident data, themes and trends

Organisational Learning Summaries

Medicines Update Blogs Safety

Learning from examples of good practice

Clinical Governance team work on strategic improvements