Strength of risk management controls in health care. (Courtesy of the clinical excellence commission, NSW
Engineering solutions are not always applicable in health care, but are the most robust and should be considered more often than they actually are. For example, following an incident where a patient received a ten-fold dose due to a syringe driver programming error, the supplier worked with NSW Health staff to reprogram these devices across the state. This is a much stronger solution than adding a sticker to warn other staff (what happens when it wears off or is no longer novel?) or educating the current staff in the local area (what happens when they move on or are backfilled by agency staff? What about other areas with the same risk?).
Another common response in health care is policy or guideline development and general education. These are considered fairly weak, but are often the only option, and if done concurrently, consistently, with reinforcement and monitoring , can result in cultural and behavioural changes required.
We also need to consider the side effects. As Reason says, “don’t cause the next adverse event while trying to prevent the last one [recurring]” . Amalberti similarly advises us to identify potential side effects whenever we make changes to processes, and to measure these. He warns us not to fall for “the Tuesday paradigm”, meaning don’t design solutions which will only work in optimal conditions, when the full range of personnel and expertise is available. Sixty per cent of acute health care in Australia occurs after normal business hours or on weekends, so we need to build solutions to fit these conditions.
In the alarm fatigue example, how can the organisation manage this risk and maintain the benefits of patient monitoring? What solutions are realistic? We need to consider what is being done by National or jurisdictional bodies, by the Colleges, and check how other similar services are tackling the problem. The Joint Commission declared medical device alarm management as a patient safety goal for 2014 , and listed specific governance and risk management activities to reduce this risk to patients. Many of these can be applied locally and should be considered for this example. As Richard Know stated after visiting the Boston Medical Centre “it may be that less technology can actually be more effective” .
Monitoring the Effectiveness of the Solutions Applied
Once solutions are identified, the organisation needs to ensure their implementation and effectiveness is monitored at all appropriate levels across the hospital, and they are modified if indicated. This is likely to include structured audits, reviews and improvement cycles.
A worked example of all the stages utilised to manage this risk are shown in Table 7.1.
Health care risk management example
Applying Risk Management Principles to Clinical Care Decisions
The worked example describes an organisational approach to a hospital-wide risk. However, as mentioned earlier, many of the clinical practices and decision-making processes used daily by the clinicians are actually risk management. They may have been built from previous formal risk management processes, application of learning from other services or sources, or from discussions between clinicians or with patients. “Steal shamelessly, but implement wisely”, as context and ownership can make or break safe practice.
Many embedded clinical risk management practices promote communication about risks at the point of care delivery. The considerations are the same as in the formal processes described above: Establish the context (what do we know about the patient’s current condition(s) and what does the health care community know about treating this?); Assess the risks (do they apply to this patient, if so, to what extent and what could happen next, as a consequence? The latter is also referred to as situational awareness ; Evaluate the risk (Should we accept the risk and proceed—or do we need to consider managing what might happen?); treat the risk (what are we going to do to reduce the risk or mitigate its harmful consequences?) Monitor the risk (Care planning would include recommendations about monitoring for any sequelae which the risk treatment did not address or may have caused). Discussing the outcome for patients in team or morbidity and mortality meetings or less formal contexts enables review and sharing of learning and continues the risk management cycle .
The aggregated learning from the application of these processes has resulted in many of the clinical structures and processes which clinicians are expected to follow. Decision support tools, protocols, guidelines and checklists have all evolved from management of identified clinical risks. For example, surgical safety checklists  and formal “rounding”  are intended to ensure staff consider the known risks for every patient and together determine how these will be managed. They also emphasise patient engagement as a vital risk management strategy. Similarly, clinical care bundles are built from information gathered about individual patient’s risks and outcomes during death reviews, incident investigations and clinical audits . They build from the individual case to recommend how care should be delivered so that patient have the best possible outcome. Utilising bundles removes the need for clinicians to reconsider every risk each time they prescribe similar treatment , for example, applying the FASTHUG bundle  when managing ventilated patients. Considering the complexity of health care risks described by Amalberti , this is an important risk management strategy which allows clinicians to focus on other components of care.
In summary risk management is all about standardising the best possible care, by supporting and steering clinicians along the right pathways, for they are health care’s greatest strength and our greatest hazard. Risk management is a core element of clinical practice and fits easily within the skill set of clinicians. Without their involvement, real change cannot occur. Safety , quality and risk management activities are pointless if they only occur in a domain removed from clinical care. This is not rocket science, but it does require a little time, optimistic problem solving and a commitment to a just, learning culture. This is another example of the importance of a team approach to health care. The bringing together of great minds, with a range of insights and practical knowledge is the best risk reduction strategy known to health care.