1 Risk in hospitals Legal Risk Clinical risk Risk arising out of - PDF document

Effective Risk Management Dr Rohini Sridhar MD FRCPA Dr. Rohini Sridhar, MD, FRCPA Chief Operating Officer, Apollo Speciality Hospital, Madurai Risk Management programme � Identification of risk � Strategies to avoid risk � Strategies to limit the impact of adverse events 1

Risk in hospitals Legal Risk � Clinical risk � Risk arising out of failure to comply with existing laws and regulations � Financial and business risk � PNDT, Human Organ Transplantation Act � Legal risk � Environmental risk � Legal liability under the Consumer Protection Act � Legal liability under the Consumer Protection Act � Operational Risk Environmental risk Operational Risk � Flood, Earthquakes and other natural disasters � Patient complaints –esp. unresolved � Security risk � Equipment failure � Fire and Electrical Safety events � Employee related risks � Risks employees may encounter in their jobs � Hazardous Material Spillage � Ri k � Risks employees bring to the workplace l b i t th k l � Radiation Hazard � Risks arising from inadequate nos/ skill sets Clinical Risk Management � 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 patients at risk of harm, and � Acting to prevent or control those risks. � Acting to prevent or control those risks 2

Near Miss Event Sentinel Event � It is a potential for harm or error which is intercepted prior to the completion of the incident/ event resulting in no harm An unexpected incident, related to system or process to the patient deficiencies, which leads to death or major and enduring loss � Most common type of error occuring in hospitals of function for a recipient of healthcare services � Provides valuable learning experience � Provides valuable learning experience Sentinel Event Sentinel Event � Sensory, motor or psychological impairment � Surgical Events � Not present at the time the service was sought or begun � Device or Product Events � Impairment unrelated to underlying condition � Patient Protection Events � Impairment lasts for a minimum period of two weeks � Environmental Events � Patient related events only � Care Management Events � Criminal Events Risk Management plan � Risk Identification and Assessment protocols � Risk Register � Risk Action plans 3

Risk Assessment Protocols Risk Assessment Protocols � Clinical : � Complete Evaluation of patient at Admission and at pre- determined intervals � ASA score – Pre-operative evaluation of patients � DVT prophylaxis: to determine which patients need DVT � Identify ‘vulnerable’ Patients prophylaxis � At higher risk of adverse events eg. Falls � Braden Score : Identify patients at risk of developing bed sores. y p p g � With special needs eg Interpreter diet � With special needs eg. Interpreter, diet � Revised Trauma Score : For triage in Emergency � Vulnerable patients are followed up more closely HAZARD VULNERABILITY ANALYSIS EMERGENCY PREPAREDNESS HVA MATRIX SCORE BOARD Hazard Vulnerability Analysis � HV A is a tool used to determine the probability, risk and Risk * @ Preparedness Probability External Event (Likelihood) response preparedness of an organisation to a natural or manmade Human Business Property Preplannin Internal * Risk rating Impact impact impact g response crisis 1.External flood 2 3 3 3 54 2 2 2 1.Earthquake 2 3 3 3 54 2 2 2 � Risk Score : Probability × risk rating 1.Internal fire 3 3 2 2 36 2 2 2 � Higher the score, more the planning and focus required � Higher the score more the planning and focus required 4. Bomb blast o b b ast 3 3 2 2 2 24 1 2 2 1.Disaster 1 1 1 1 1 1 1 1 Tsunami 6. Drought 1 1 1 1 1 2 2 2 7. Road/train 3 3 1 1 9 2 2 2 accident 8. Epidemic 3 3 2 1 18 1 1 1 9. Industrial 2 2 1 1 4 1 1 2 accidents 4

SAFETY / FIRE SAFETY PREPAREDNESS HVA MATRIX SCORE BOARD HAZMAT PREPAREDNESS HVA MATRIX SCORE BOARD External Risk * @ Preparedness resp Probability onse Event (Likelihood) Human Property Internal * Business Preplannin Imp impa Risk rating resp impact g External act ct onse resp Risk * @ Preparedness Probability 1. Engineering onse 3 3 2 2 36 2 2 2 Activities Event (Likelihood) Human Property Internal * Business Preplannin 2. Employee Imp impa Risk rating resp 3 2 2 2 24 2 2 2 impact g Safety act ct onse 3. Contractor 3. Contractor 1 Major hazmat 1. Major hazmat 3 3 3 3 2 2 1 1 18 18 2 2 2 2 2 2 2 2 3 2 24 1 1 2 Safety spill. 4 Fire Safety 3 3 3 2 54 2 2 1 2. Radiology 2 2 2 1 8 1 1 1 exposure 5. Fire Equipment 2 3 3 2 36 1 2 1 Failure 3. Lab chemical 2 2 3 3 36 1 1 1 storage 6 CGSS Fire 2 3 3 2 36 1 2 2 4. Small / 7. Power Plant 2 3 3 3 54 1 1 1 medium 3 2 1 1 6 1 1 1 Fire internal spill 8. Operation Theatre 2 2 3 3 36 1 2 2 Fire 9. Hazmat Fire 2 2 2 2 16 1 2 2 SECURITY PREPAREDNESS HVA MATRIX SCORE BOARD BIOMEDICAL ENGINEERING HVA MATRIX SCORE BOARD External Risk * @ Preparedness resp Risk * @ Preparedness Probability Probability External onse Event (Likelihood) Event (Likelihood resp Human Business Property Internal Human Property Internal Preplannin * ) * onse Business Preplannin Imp impac impa Risk rating resp Imp impa Risk rating resp g impact g act t ct onse act ct onse 1. Theatre Light 1. Theft / 1 3 2 1 6 1 1 2 3 1 3 1 9 2 1 2 Failure Pilferages 2. Theatre Table 2. Abduction 2 3 1 2 12 1 1 2 1 2 1 2 4 1 1 3 Failure 3. Missing 2 2 2 2 NA NA 2 2 8 8 1 1 1 1 2 2 3 Blood Gas 3. Blood Gas Patient Machine 2 2 2 2 16 1 2 2 Failure 4. Security 2 2 2 2 16 2 2 2 Threat 4. Ventilator Failure Or 2 2 2 2 16 1 1 1 5. VIPs Protocol 2 1 1 2 4 2 1 1 Shortages 5. ETO 6. Bomb Threat 3 3 3 3 81 2 1 1 Equipment 2 2 3 1 12 1 1 1 Mal 7. Terrorist 2 3 2 3 36 2 1 1 Function Attack 6. MRI Mal 8. Crowd Control 2 1 2 1 4 1 2 2 3 1 2 2 12 1 3 1 Function 9. Traffic Control 1 2 2 1 4 2 1 1 7. CT Scanner Mal 3 1 2 2 12 1 3 1 Function Patient Education Strategies to Prevent Risk � Patient and Employee education � Brochures and booklets � Good Clinical Practice and protocols � Pictorial displays and charts � Good facility Maintenance � Counselling about specific risks: � Facility Audits � Food-drug interactions, � Activities of Daily Living � A ti iti f D il Li i � Clinical Audits � Hand washing and Hygiene 5

Clinical practice APOLLO SPECIALITY HOSPITALS CENTRAL LINE BUNDLE COMPLIANCE CHECKLIST � Implemenation of care bundles in ICU � V entilator bundle � Central line bundle DATE NAME AGE/ UHID WARD CONS SITE DAYS HAND MAX CLORHEX DAILY REMARKS SEX HYGIENE BARRIER SKIN REVIEW � Presurgical Checklists ASEPSIS � Clinical Pathways � Cli i l P th Example 2 Appendix A VENTILATOR BUNDLE CHECKLIST Example 1 (Individual Patient) Patient: VENTILATOR BUNDLE CHECKLIST Admit Date: Sedaton Vaction & Assessment of HOB 30 ° Date Bed/Pt initials PUD Prophylaxis DVT Prophylaxis ICU Day 1 2 3 4 5 6 7 8 9 10 Readiness to Extubate 1. Head Of The Bed 30° 2. Daily Sedation Vacation and Daily Assessment of readness to extubate 3. PUD Prophylaxis 4.DVT Prophylaxis 6

HOSPIT HOSPIT AL RISK RISK REGIS REGISTRY Department: Departmen Description of the risk Risk assessment Person Actions Preventive Signature & t Code, Type Risk involved taken actions name of the Risk No & rating identified Reporting Date Employee Department: • Department code to suffix, if Housekeeping – then it will be HK/01/5 th J an ‘ 07 • Risk Assessment : All risks, whether resulting from accident, incident, errors or risk assessment can be evaluated and graded. This includes near misses too. TYPE LIKELIHOOD CONSEQUENCE RISK RATING Frequent Catastrophic Very High A Probable Significant High B Unlikely Moderate Medium C Remote Negligible Low D Risk Action plan � ‘Blame free’ and prompt reporting � Provide education to all staff of Clinical Risk � Root cause Analysis Management principles � Remedial Measures to minimize the consequence of adverse � Promote a cultural change in the organisation by event encouraging clinical and non clinical staff to proactively � Preventive measures to reduce recurrence of similar risk P i d f i il i k identify potential risks and facilitate process redesign to id tif t ti l i k d f ilit t d i t � Review of effectiveness reduce risk � Further encourage a 'just' culture where the emphasis is on process and system redesign to improve safety Employee level Strategic level � Education about risk identification � Risk Management Committees – eg. Safety, Medication, Radiation Safety, Transfusion � Standard Operating Procedures � Review the risk register and the effectiveness of action to � Employee safety Measures reduce and prevent risk � Risk reporting formats � Develop and recommend policies to reduce and prevent risk � Develop and recommend policies to reduce and prevent risk 7

Risk Management Education Corrective Identification Action Root Cause Reporting Analysis 8