The Role of Risk Management in Patient Safety

What is Risk Management? Risk management is defined as the process of planning and controlling the activities of a corporation in order to minimize the effects of risks of an organization’s capital and earnings (Yong, 2007). Risk Management expands the process from just accidental losses but also financial, strategic and operational and other risks. The purpose of Patient Safety in connection with risk management is to provide safe and effective care to the patients by creating a safe environment (Gait, 2006). An organizational culture focused on safety and the prevention of errors; a staff that is aware of and educated about safety risks and error prevention; internal reporting of errors, near misses, and risks to safe care; focus on process improvement rather than aiming blame (Gait, 2006). All health care systems have the potential to unintentionally harm the people they are trying to help through inappropriate decisions and medical errors. Since the 1990s, a powerful body of scientific evidence analyzing the occurrence and impact of adverse events occurring world wide has accumulated (Pittet, 2006). Although there is much debate about the exact size of the problem, few would disagree that it is an important source of morbidity and mortality (Pittet, 2006).

 Patient safety along with risk management is implemented through the oversight of a Patient Safety Management Committee in conjunction with numerous other active programs and efforts, including the Quality Management Program, Environment of Care program, Infection Control program, human resource activities and other hospital committees and teams (Humble, 2007).

Patient safety is the responsibility of each and every staff member. Administrative and medical staff leaders are responsible for creating a culture of safety and for making patient safety a priority. The Board of Trustees of the Hospital Authority has designated responsibility for the management and oversight of the organization-wide patient safety program to the Patient Safety Team, led by the Chief Medical Officer (O’Reilly, 2007). The Patient Safety Team is comprised of representatives from Quality Management, Nursing, Medical Staff, Compliance, hospital operations, and Risk Management. The Patient Safety Team monitors and reviews the activities of safety work groups, which are designated for the purpose of targeting a specific patient safety initiative (O’Reilly, 2007). Focused safety work groups are designed to collect data, perform analysis, draw conclusions, and make recommendations aimed at improving patient safety to the Patient Safety Team. Additionally, proactive risk reduction activities, when deemed appropriate and possible, are correlated to other organizational initiatives (e.g., staffing effectiveness). (O’Reilly, 2007).

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 The Team works in direct collaboration with the Patient Safety & Management Committee and the Quality Management and Risk Management Departments. The program is supported by the organization through the allocation of financial, information, physical, and human resources (O’Reilly, 2007). The scope of the Patient Safety encompasses integration of and participation by all hospital departments and medical services; staff education; patient education; data collection and analysis; process design/re-design and implementation; monitoring and auditing; internal and external reporting; the handling of adverse unanticipated patient outcomes, including disclosure to patients/families and staff counseling; and participation in research projects (O’Reilly, 2007).

The program is designed to include all patient populations rendered care by visitors, medical staff, employees, volunteers, and agency/contracted staff (O’Reilly, 2007). The type of patient safety concerns addressed include the following occurrences reported through the Critical Indicator Occurrence Reporting System; adverse events, sentinel events, near misses, and unusual events; patient safety risks identified by internal sources such as: anonymous reporting, staff and patient surveys, the peer review program, indicator monitoring, and quality management program; and patient safety risks identified by external sources such as: JCAHO Sentinel Event Alerts and National Patient Safety Goals, Patient Safety Foundation, and Institute of Medicine (O’Reilly,2007).

Patients have the right to be informed about the outcome of their care, including unanticipated outcomes. Patient Safety along with Risk Management believes that when a health care injury occurs, the patient and the family or representative are entitled to a prompt explanation of how the injury occurred and its short- and long-term effects (Dunn, 2007). When an error contributed to the injury, the patient and the family or representative should receive a truthful and compassionate explanation about the error and the remedies available to the patient. They should be informed that the factors involved in the injury will be investigated so that steps can be taken to reduce the likelihood of similar injury to other patients (Denham, 2007). Disclosure should be made by the most appropriate medical staff member and/or administrator and documentation of the conversation should be made in the patient’s medical record

(Humble, 2007).

 The types of Risk Exposure we will be discussing in this work will be: Adverse event, Sentinel Event, Unusual Event, Near Miss, Hazardous Condition, Error, and Intentional Unsafe Acts, Risk of Loss of Physical Assets, Risk of Delay or Shortfall of Performance, Credit Risk, Legal Risk, Risk of Information Gathering and Processing, Workplace Safety , Health Risk (Pexton, 2005).

An adverse event is an occurrence or condition that causes unexpected harm to a patient during the provision of care or services. Adverse events may be acts of commission or omission and are usually documented on an Occurrence Report Form and are reported within 24 hours to the Risk Management Office. When a medical/healthcare error results in an adverse event, the following procedures should be followed in order to provide an immediate response (Pexton, 2005):

Provide needed patient care, contain the risk, preserve factual information, report the occurrence, provide support for staff involved, and preserved confidentiality (Pexton, 2005).

After ensuring that an effective immediate response has been undertaken, the organization then conducts an intense analysis of the event. The purpose of the analysis is to identify the basic or contributing causal factors associated with the adverse event (Pappas, 2007).

Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. The subset of sentinel events that is subject to review by the Joint Commission includes any occurrence that meets a criteria (Suresh, 2007).

Each JCAHO Sentinel Event Alert and Patient Safety Goal will be routed to the appropriate committee/team for consideration of the recommended risk-reduction strategies (Suresh, 2007). The team/committee will act on the sentinel event alert within 90 days and will subsequently educate the organization about the sentinel event alert and its efforts to reduce risk and promote patient safety regarding the topic discussed in the sentinel event alert (Suresh, 2007).

The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition, or The event is one of the following (even if the outcome was not death or major permanent loss of function unrelated to the natural course of the patient’s illness or underlying condition) (Pronovost, 2007).

Suicide of a patient in a setting where the patient receives around-the-clock care (e.g., hospital, residential treatment center, crisis stabilization center) Unanticipated death of a full-

Term infant abduction or discharge to the wrong family Rape Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities Surgery on the wrong patient or wrong body part (Shannon, 2007). An adverse outcome that is directly related to the natural course of the patient’s illness or underlying condition, e.g., terminal illness present at the time of presentation, is not reportable except for suicide in, or following elopement from, a 24-hour care setting (Shannon, 2007).

Unusual Event is an unexpected occurrence or accident resulting in death, life threatening or serious injury to a patient that is not related to a natural course of the patient’s illness or underlying condition. An unusual event also includes an incident resulting in the abuse of a patient. Near Miss is any process variation which did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome. Such a near miss falls within the scope of the definition of a sentinel event, but outside the scope of those sentinel events that are subject to review by the JCAHO under its Sentinel Event Policy (Humble, 2007). Hazardous Condition: Any set of circumstances (exclusive of the disease or condition for which the patient is being treated) which significantly increases the likelihood of a serious adverse outcome (Humble, 2007). Error: An unintended act, either of omission or commission, or an act that does not achieve its intended outcome. Intentional Unsafe Acts: Any event that results from a criminal act; a purposefully unsafe act; an act related to alcohol or substance abuse; or events involving alleged or suspected patient abuse by a privileged provider, staff member, volunteer, contractor, or trainee. Intentional unsafe acts are not within the definition of adverse events and should be addressed through avenues other than the Patient Safety Program (Steiger, 2007).

 In order for patients to fulfill their responsibilities for patient safety, they must be educated. Thus, the Patient Bill of Rights & Responsibilities has outlined the patient’s right to be informed about his/her care and about his/her responsibility to be involved by asking questions and participating in decision making. As appropriate to his/her condition, the patient is considered to be a partner in the health care process (Short, 2007).

Additionally, mechanisms are in place to educate patients about safe medication use, safe medical equipment use, drug-food interactions, and nutrition and modified diets. The patient satisfaction survey is designed to capture patient feedback about patient safety in regard to these and other patient safety factors (Prince, 2007). Patient Safety Factors Internal could be any staff member that is aware that a hazardous condition exists or that an adverse patient outcome or sentinel event has occurred, is obligated to report the situation to one of the following: his/her supervisor, Administration, Risk Management Nursing Supervisor, Administrator-on-Duty. In order to encourage reporting, a number of reporting methods are available to staff: the occurrence reporting system, direct conversation, and Hotline (Prince, 2007).

Patient Safety Factors External could be the following immediate notification and verification that an adverse patient event has occurred, administration will make the required notifications to external authorities such as: police, medical examiners office, the State, etc (Hoff, 2007). Additionally, the Compliance & Regulatory Department notifies the hospital’s medical malpractice insurance carrier and the hospital’s legal counsel. The CEO/COO will ascertain the situation and determine communications with the Board of Trustees and other officials (Humble, 2007).

Policy making for risk management should be established if a business or clinical process is contributing or creating risk scenarios in all departments. Policies for risk management should be evaluated if the current processes in place are following acceptable rules and regulations without causing manage care to be fined or have legal action taken against the business or clinical settings. Incidents reporting mechanisms should be put in place such as incident reports, attorney requests, quality assurance studies, and legal complaints and suits (Yong, 2007).

Risk Management provides the most practical, authoritative guidance

available for Healthcare risk managers covering the broad range of challenges you face,

including: improving Patient safety; complying with government programs like EMTALA

and HIPAA and making them work to your facility’s benefit; reducing medical errors;

staying on top of developing legislation and regulations; interpreting recent court

decisions and determining whether they affect your facility, and if so, how (Carruthers,

2006). The objectives of Risk Management are to: describe legal, clinical, financial, and

managerial issues pertinent to risk management in health care; explain how these

issues affect nurses, doctors, legal counsel, management, and patients; identify

solutions, including programs used by government agencies and other

hospitals, for hospital personnel to use in overcoming risk management challenges

they encounter in daily practice (Carruthers, 2006).

Risk of loss can cause exposure to business loss which can include market fluctuation where services are not being utilized by patients or they may be going to other competitors with the same services (Carruthers, 2006). Risk of loss of physical assets is previously was having issues with running and maintaining equipment used by clinical staff to treat and diagnose patients. The lack of maintenance of the equipment serves as a risk of disruption to operations. The nurses who are stealing the medication are reducing revenue as pharmaceuticals are expensive and these would have to be replaced in order to service our patients (Carruthers, 2006).

Next, risk of delay or shortfall of performance has had a recent issue with some physicians choosing to resign from the urgent care facility. This will cause a delay with evaluating and/or treating patients. The shortage may induce the staff to work faster which could result in staff making mistakes that could result in malpractice suits or a sentinel event which can results in fines, penalties and lawsuits (Tregunno, 2007). Another potential risk, credit risk can occur from non-payment of patients for services that they have been rendered. Extra revenue may have to be used for collection of funds in order to generate revenue. Legal Risk is not compliant with state and federal mandatory regulations the risk of exposure to fines penalties and possible closure of the facility can occur (Beifuss, 2007). Professional liability is affected by this as well. The nurses who are stealing the drugs could have their licenses suspended and could face criminal and legal proceedings. The facility has the corporate responsibility for any negligent act that their employees do (Beifuss, 2007).

Risk of Information Gathering and Processing of medical information can be exposed to risks by not following the Health Information and Portability and Accountability Act of patient record confidentiality, and guidelines on how protected health information can be shared with other entities or designated representatives of the patients (Conico, 2002). Workplace Safety and Health Risk is the employers’ financial and legal responsibility to provide care and insurance for any work-related injury. Offering this type of protection for employees will result in retention, loyalty and a good reputation for the company (Gradle, 2002).

Policy making for reducing the possibility of risk could be risk identification and it should be identified if a business or clinical process is contributing or creating s risk scenario in all departments (Carruthers, 2006). It should be evaluated if the current processes in place are following acceptable rules and regulations without causing to be fined or have legal action taken against us. Incident reporting mechanisms should be put in place such as incident reports, occurrences, patient complaints, security reports, attorney requests, quality assurance studies and legal complaints and suits (Shojania, 2007).

Next, claims management is a process where the risk manager manages all claims against the facility and conducts investigations on whether the facility or individuals followed all processes and were in compliance with the enforced rules and regulations of the facility. The data from the claims handling process will be useful in identifying risks and what areas in the facility that may need training or in-services to keep up with all the changing external policies and regulations (Moynihan, 2002).

Data Management is the compilation of all incident data in order to do a trend and analysis study and primarily for loss prevention. Data will be collected by the data base manager who will compile the data that can be used for Quality Assurance and Clinical Quality Indicators. These reports will be reviewed monthly by the governing board and department heads (Moynihan, 2002).

Risk Management education and training of staff is mandatory in some states that do require this (Hoff, 2007). This would consist of an orientation program that would be given to new employees and clinical staff. These would be specific programs related to their job functions. After the orientation, the employees should sign a verification form that states that they have attended the orientation and that they understand the risk management and regulatory policies that are enforced in the facility. Risk Financing is a process where the risk manager would be responsible for all insurance policy documents, schedules of coverage that contains policy periods, insurers’ brokers. This all should be made readily available (Longo, 2007).

Patients and quality leaders continue to call for delivery of patient-centered care. If

climates that facilitate such care are also related to improved patient safety and nurse

satisfaction, proactive, patient-centered management of the work environment could

result in improved patient, employee, and organizational outcomes (Longo, 2007).

In conclusion, Risk management is an effective tool in early intervention and

sympathetic care after an accident injury to a patient (Pozgar, 2003). Patients are

counting on those who take care of their safety. The Risk Management and Patient

Safety was developed to meet the risk, quality, claims management and patient safety

needs of the health care industry with a primary focus on clinical risk reduction, quality

patient outcomes, education and claims management (Litch, 2007). Program

effectiveness can be determined in a multitude of ways, including the

extent in which improvements were made in the high-risk process selected for pro-

active risk reduction. The improved results on patient safety questions contained in the

patient satisfaction surveys, improved results on the staff survey regarding an

organizational culture for safety and error reporting (Hoff, 2007). With the increased

reporting of errors, near misses, and hazardous conditions is our goal as a Risk

manager is to support health care organizations, clinics, community health centers and

providers in reducing medical error, assisting in regulatory compliance, and ultimately

enhancing patient safety while controlling loss. This task has now become the law and it

will take effort n the part of everyone who is healthcare professionals (Litch, 2007).

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