Chapter 1

Understanding Risk

Risk enters our lives from the moment of conception, from our first breath of air to our last. We spend our lives trading risks for rewards and each one of us trades from a different perspective. It can be said that:

• risk-taking is influenced by the rewards

• perceptions of risk are influenced by experience of losses – one’s own and others

• risk-taking involves balancing between the propensity to take risk and the perceived risk.

Definitions

Risk is the possibility of loss, injury, disadvantage or destruction. It is the probability that a given hazardous event will occur and that this event will have consequences, which are deemed to be negative by some, or all of those who are exposed to it.

People use the word “risk” in different ways and it is a widely misunderstood term. “Risk” is sometimes incorrectly used to mean the hazard itself such as in the statement: “The risk is that he will die skydiving”, or (correctly) risk can relate to probability as expressed in the statement: “The risk of dying from skydiving is small”.

Risk is the probability that a hazard will give rise to harm. It is not the same as uncertainty. Risk is when you don’t know what will happen but you do know the probabilities; uncertainty is when you don’t even know the probabilities.

We can define the terminology in the following way:

• Hazard – condition/circumstances with potential for causing or contributing to injury or death. A hazard is anything that might cause a risk.

• Risk – the probability or likelihood of injury or death.

• Danger – product of hazard or risk.

• Uncertainty – inability to make a deterministic prognosis.

Perceptions of Risk

In his book Risky Business Professor John Adams of University College London identifies three types of risk:

1. Directly perceptible risks – these are the risks we deal with instinctively and intuitively like crossing the road. In this situation, we become our own risk managers.

2. Risks perceived through scientific study – for example, the harmful effects of smoking and drinking on oral soft tissues can be understood through scientific study by examination of cellular changes. We know about these risks and we communicate them to our patients, but many patients will continue with their habits.

3. Virtual risks – these are culturally constructed when the science is inconclusive; it allows people to perceive the risk according to their pre-existing beliefs and prejudices. It also gives the media a freehand to write catchy headlines to attract readers’ attention. For example, many dentists have been asked about the alleged risks to health from mercury in dental amalgam and have experienced the perceptual variations amongst patients when discussing the issue.

These variations arise because the perception of virtual risks is altered by the way we view the world. Adams proposes a four-fold typology, which categorises people into different groups; this helps to understand the variations in perception (Table 1-1).

Patients’ reactions to risk often have their own rationality. In most dentist-patient interactions, the dentist is the expert and the patient the layperson. Dentists may spend time communicating with patients about the risks associated with poor oral hygiene; however, the patients may perceive the risk from a totally different perspective (Table 1-2).

Source: Based on slovic P. Trust, emotion, sex, politics and science: surveying the risk-assessment battlefield. Risk Analysis 1999;19:689–701.

We must learn to manage these perceptions in risk communication. Dr. Vincent T. Covello, an internationally recognised expert in the field of risk communication and Director of the Center for Risk Communication in New York, has identified the key factors that play an important role in the perception of risk (Fig 1-1). In a presentation at the Center for Risk Communication in 2002, Covello noted that: “There is virtually no correlation between the ranking of a threat or hazard by experts and the ranking of those same hazards by the public”.

Covello made it clear in his study that trust is a key element in the communication process – if patients trust the dentist they are more likely to take heed of risk communications. This is reflected in everyday practice where a patient who is presented with a range of treatment options with the pros and cons, will in a strong dentist-patient relationship request the dentist to undertake what he or she feels is “best” for them.

Risk Categories in General Practice

Kahn has suggested a list of risk criteria, which apply equally to general practice as to the hospital environment for which they were first identified. These are:

• potential for litigation

• possibility of erosion of reputation and confidence

• a breach/threat to security of premises, facilities, equipment or staff

• significant actual or potential injury to patients or team members

• minor incidents

• significant occupational health and safety hazards.

In his excellent book Risk Management in Dentistry Roger Matthews supports Kahn’s criteria and has written: “A practising dentist today will at some point be faced with a potential loss from an event meeting one or more of these criteria.” His words were penned a decade before the claims and complaint culture grew exponentially in the UK. The broad categories of risk affecting dentists in general practice are summarised in Table 1-3.

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