Risk management Flashcards
What percentage of claims do paediatrics make up?
2% NHSLA 2016
What percentage of value of claims do paediatrics make up?
8% NHSLA 2016
What is a hazard?
Situations with the potential to cause harm. NPSA 2007
What is a risk?
A risk is the combination of likelihood and consequence of a hazard being realised. NPSA 2007
What is a clinical risk?
The chance of an adverse outcome resulting from clinical investigation, treatment or patient care. NPSA 2007
What is risk management?
Analysing the causes of errors and limiting the incidence of errors … creating systems better able to tolerate the occurence or errors. Ernstmann 2009
What is the risk score in the case study?
Risk score = conseuqnece x likelihood (NPSA 2007)
High risk = possible x major
12 = 3 x 4
What is leadership?
Leadership is a process whereby an individual influences a group of individuals to achieve a comon goal (Northouse 2010)
What is a transformational leader?
A transformational leader is a leadership style where the leader, by example, inspires followers to reach their full potential and be the best they can be (Steaban 2016)
What is a manager?
Managers plan, allocate resources, administer and control (Gill 2005)
What is the managing risk theory called?
Systems safety in healthcare (Vincent et al 2013)
What is systems safety in healthcare based on?
James Reason (2000) -> London protcol (Vincent et al 2013) -> NPSA (2010a) Contributory factors analysis tool
What is the Contributory factors analysis tool used for?
Incident investigations (NPSA 2010a) Identify latent conditions which underpin active failures (Vincent et al 2013)
What are the 6 factors from the root cause analysis?
Pirate traitors can walk over edge
- Patient Factors
- Task Factors
- Communication
- Work environment
- Oranganisational
- Education/training
What are the patient factors and why are they important?
- Seriousness of condition - septic shock in patients with febrile neutropenia most common cause of death in childhood cancer (Wright and langford 2010)
- Age related issues - age 13, parent not present, unable to explain need for antibiotics
What are the task factors and why are they important?
- Guidelines either not there or not adhered to - re: what to do if no IV giver
What are the communication factors and why are they important?
- Lack of info to patients - re: no IV giver
- Ineffective communication to staff up, down and across - did staff who accepted patient know there was no IV giver? Could paeds oncology or A&E have started IV antibiotics?
What are the work environment factors and why are they important?
- Inappropriate skill mix
2. Low staff/patient ratio - shortage of staff Band 2, 4, 5, 6, 7
What are the organisational factors and why are they important?
- Lack of risk management plan - re: no IV giver
- Acceptance/toleration of inadequate adherence to current practice - acknowledgement that this could be precursor to a worse event
What are the education/training factors and why are they important?
- Lack of knowledge - re: neutropenic sepsis
2. Lack of skills - re: IV giving
What are the professional considerations?
- NMC (2015) Duty of candour
- NMC (2015) The code - “recognise and work within the limits of your competence”
What are the ethical considerations?
- Non-maleficence is the principle of causing no harm (Beauchamp and Childress 2013) - importance of risk management and of not allowing patient to progress into neutropenic sepsis
- Beneficence is the principle of acting to benefit other people (Beauchamp and Childress 2013) - find a way to give IV antibiotics
What are the legal considerations?
Civil law - three elements to prove negligence - Dixons and Evans 2006)
- Duty of care
- Breach in duty of care by ommission or comission (e.g. not giving IV antibiotics)
- Causing forseeable harm
What are the policy considerations?
A promise to learn (Berwick 2013)
- Patient safety above all other aims - ward metrics show patients think safety is variable
- Listen to patients and carers at all times - ward metrics show not listening or communicating to patients or carers
- Embrace transparency
