3.

6 Clinical Risk Management

Risk can be defined as ‘the likelihood, high or low, that somebody or something will be harmed
by an unwanted event or incident, multiplied by the severity of the potential harm’. Clinical risk
management (CRM) is an approach to improving the quality and safe delivery of health care by
placing special emphasis on identifying circumstances that put staff/patients at risk of harm and
acting to prevent or control those risks.

Risk management involves assessing the environment for potential risks to patients and staff then
taking action to minimize any risks identified. The process of risk management seeks to answer
four simple, related questions:

How bad?

Is there a need for

What can go wrong?
action?

How often?

Figure 1 Risk management

Risk management proactively reduces identified risks to an acceptable level by creating a culture
founded upon assessment and prevention, rather than reaction and remedy.

Risk assessment looks at:

 Hazards – which are situations with the potential to cause harm; and
 Risks - which are defined as the probability that a specific adverse event will occur in a
specific time period or as a result of a specific situation.

Risk assessment involves 5 steps

Step 1 Identify the hazards (what can go wrong?): Take into account the things that have gone
wrong in the past and near miss incidents. Walk around the workplace and talk to patients
 and staff. Map or describe the activity to be assessed. It may be necessary to involve a
multidisciplinary team.

Step 2 Decide who might be harmed and how (what can go wrong, who is exposed to the
hazard)?

Step 3 Evaluate the risks (how bad? how often?) and decide on the precautions (is it necessary to
take further action?) A risk matrix, such as that presented in Table 3 below can be used to
evaluate the risks

Step 4 Record the findings, proposed action and identify who will lead on each action

Step 5 Review the risk assessment and update if needed

Table 3 Risk Assessment Matrix

Catastrophic Yellow Orange Red Red Red

Major Yellow Orange Orange Red Red
Consequence

Moderate Green Yellow Orange Orange Red

Minor Green Yellow Yellow Orange Orange
Negligible Green Green Green Yellow Yellow
Rare Unlikely Possible Likely Almost
certain
Likelihood

Low risk (green) – quick, easy measures should be implemented immediately and further action
planned when resources permit.

Moderate risk (yellow) – actions should be implemented as soon as possible, but no later than
one year.
High risk (orange) – actions should be implemented as soon as possible, but no later than six
months.
Extreme risk (red) – action should be taken immediately.

Hospitals should establish systems to regularly assess risk arising from the provision and
delivery of healthcare and should ensure that steps are taken to minimize risk. Each case
team/department should regularly (for example quarterly) conduct a risk assessment and identify
actions to minimize risk to patients. The whole team should be involved in the risk assessment in
an open, learning environment. Areas that could be considered by the case team include, but are
not limited to:
 The physical environment – is it clean, safe, free from hazards such as broken furniture or
equipment?
 Are emergency exits clearly labelled and free from obstruction?
 Are infection prevention policies and procedures implemented adequately?
 Hazardous materials – are these stored safely and securely?
 Is all equipment in good working order, is maintenance required to minimize errors and
breakdowns?
 Are policies for medication administration implemented to minimize drug error?
 Are policies for laboratory sample collection, analysis and reporting implemented to ensure
that the correct specimen is taken from the correct patient and that accurate results are
obtained and reported in a timely manner?
 Are clinical guidelines adhered to in order to ensure evidence based clinical practice?

A ‘Safety Walk-Round’ is a second approach to Risk Management. A ‘Safety Walk-Round’ is

where a group of hospital leaders/quality team members and other staff visit areas of the hospital
and ask front-line staff about specific events, contributing factors, near misses, potential
problems and possible solutions. The leaders then prioritize the events and the case
team/department is asked to develop solutions. The information gathered in this process often
has the solution embedded in the event description. Thus, this process can often result in prompt
changes that improve care and safety. It also can lead to culture change, as the concerns of front-
line staff are addressed and as front-line staff are engaged in continuous observation of hazards
and solutions for discussion with senior leadership. Leadership Walk-Rounds are a low-cost way
to identify hazards of concern to front-line staff and make needed changes. They require no
additional staff, equipment, or infrastructure.
Appendix B Sample Risk Assessment Template

Date of Risk Assessment: dd/mm/yy

Case Team/Service Area: Example- Operating Theatres
Participants who took part in Risk Assessment: (list names and positions)

Risk Assessment Matrix:

Catastrophic Yellow Orange Red Red Red

Major Yellow Orange Orange Red Red
Consequence

Moderate Green Yellow Orange Orange Red

Minor Green Yellow Yellow Orange Orange
Negligible Green Green Green Yellow Yellow
Rare Unlikely Possible Likely Almost
certain
Likelihood

Safe: Service/Team leaders/Managers are responsible for maintaining a risk register based on an
on-going programme of risk assessment, informed by incident reporting, records review, audit
and other methods.

The management team have a responsibility to ensure that staff operate in a safe working
environment and that any risks that are identified are mitigated as far as is reasonably possible by
changing practice or provision of appropriate equipment/resources.

The management teams have a responsibility to ensure all policies and procedures are followed
appropriately and to investigate any breach, complaint or incident that occurs to ensure safe
practice is followed at all times.
Hazard identified Consequence(negligibl Likelihood(rare, Category(green, Action to be Responsible Date for
e, minor, moderate, unlikely, possible, yellow, orange, taken person completion of
major, catastrophic) likely, almost red) action
certain)

1. Old broken equipment in Moderate Likely ORANGE Remove Head of Case Within one week
corridor and potential that equipment to Team(name) by dd/mm/yy
patients or staff may trip and maintenance
fall, or injure themselves on department
the items

2.No sharp boxes available Major Likely RED Install sharp Senior Within two days
and potential to cause boxes Nurse(name) by dd/mm/yy
needle-stick injury to staff
or patients

3.Interrupted electrical Catastrophic Possible RED Back-up CEO As soon as

supply potential for failure generator to be possible, no later
of lights, anaesthesia installed than 3 months
machine during surgical dd/mm/yy
procedure and hence patient
harm

4.Shortage of nursing staff Catastrophic Possible ORANGE Add more Case Team Head Within three
to monitor patients in nursing staff to and Head of months, i.e. by
‘recovery’ area and potential department or Human Resource dd/mm/yy
harm due to poor monitoring change skill mix Department
and clinical care of existing staff

5.Lack of pre-surgical Major Possible ORANGE Prepare pre- Senior Within two
checklist and potential for surgical checklist Surgeon(name) months, i.e. by
cancelled surgery because and train ward dd/mm/yy
patient not prepared staff in its use
adequately