R3 Wissarut Thanomphruetthikul
Department of trauma and emergency medicine
Phramongkutklao Hospital
introduction
• Risk :
o Probability/threat of damage, injury, or loss caused by vulnerabilities
o Preventable by proactive actions
• Probability : Likelihood that an event will occur
• Threat : Activity representing potential danger
• Vulnerability : Weakness that can be exploited
• Loss : Compromise to functions, life, or assets
risk management in healthcare page 1
introduction
• Healthcare systems are inherently risky due to
o Complex technology
o Intensely complex procedures
o High service demand
o Time pressure
o High patient expectations
o Hierarchical training and responsibilities
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introduction
• WHO: In developed countries, 1/10 patients is harmed during hospital care
• AHRQ 2013: In U.S. hospitals, harm rate is 25.1/100 admissions
• IHI: Medical errors are the 3rd leading cause of death in the U.S., after heart
disease and cancer
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types of risk
1. General risk : Risks or chances of experiencing loss or unintended harm
that are not directly related to patient care
o Loss of property
o Verbal disputes
o Water pipe leakage
o Misuse of resources
o Hospital vehicle accidents
o Incorrect registration of rights
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types of risk
2. Clinical risk : An event that may pose a danger to patients, arising from the
processes of service delivery, diagnostic procedures, medical treatment,
or unintended clinical interventions
Common clinical risk Specific clinical risk
• Diagnostic errors • Normal labor → Postpartum hemorrhage
• Hospital-acquired infections • Myocardial infarction → Shock, heart failure
• Accidents during treatment • Diabetes mellitus → Hypoglycemia/Hyperglycemia
• Adverse reactions from medications or blood • Upper GI bleeding → Hypovolemic shock
transfusions
• Medication or blood administration errors
• Patient falls
• Incorrect lab results or X-ray interpretation
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severity of the incident
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risk management
Key Concepts
o Risk management in healthcare
➢ A structured effort to identify, assess, and reduce risks
➢ Aimed at patients, visitors, staff, and organizational assets
o Best approach:
➢ Use a proactive strategy to detect and manage risks before they
occur
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risk management
Key Concepts (cont.)
o If an incident has already occurred
➢ Post-event handling should still follow risk management principles
o Purpose of this material:
➢ To provide a clear and concise overview
➢ Help healthcare professionals quickly understand key concepts
➢ Enable practical implementation in their organizations
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risk management
Five Basic Steps
o Step 1: Establish the context
o Step 2: Identify risks
o Step 3: Analyze risks
o Step 4: Evaluate risks
o Step 5: Treat/Manage Risks
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step 1: establish the context
• Context is essential in identifying and managing risks
• Certain clinical areas carry higher risk and need focused attention in risk
management
o ICU / CCU
o Operating Room
o Emergency Room
o Blood transfusion services
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step 2: identify risks
Risk identification is the process by which
o Healthcare professionals and staff become aware of risks
o Within healthcare services and the working environment
• Identified risks should be documented using the Risk Management Tool
(RMT)
RMT is also known as the “Risk register”
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step 2: identify risks Risk Management Tool (RMT)
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step 2: identify risks
• Sources of Risk Identification
o Discussions with department chiefs, managers, and staff
o Patient tracer activity (tracing the journey of a patient from admission
till discharge)
o Retrospective screening of patient records
o Reports of accreditation bodies
o Incident reporting system & sentinel events
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step 2: identify risks
• Sources of Risk Identification (cont.)
o Healthcare associated infections (HAI) reports
o Executive committee reports
o Facility management & safety committee report
o Patient complaints and satisfaction survey results
o Specialized committee reports
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step 3: analyze risks
• Risk analysis involves understanding the nature of identified risks
o Level of the risk or Risk score Risk matrix
o Underlying causes Root Cause Analysis (RCA)
o Existing control measures : put in place to eliminate or reduce the risk
Consider the adequacy, implementation, and effectiveness
e.g. Policies, procedures, protocols, guidelines
Alarms and beeps
Engineering controls
Insurance coverage programs
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step 3: analyze risks
Risk Score Calculation
Risk Score (R) = Likelihood (L) × Severity of Impact (S)
➢ Risk score : Prioritize the risk
➢ Likelihood : Probability of future occurrence [Based on the expertise,
knowledge and actual experience of the group scoring the likelihood]
➢ Severity of impact : Impact of harm to service user, employees, service
provision, environment, or the organization
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step 3: analyze risks
Risk Score Calculation
Risk Score (R) = Likelihood (L) × Severity of Impact (S)
Scored from 1 (Rare) to 5 (Almost certain)
Guide to likelihood scoring
“Higher control effectiveness = Lower likelihood”
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step 3: analyze risks
Risk Score Calculation
Risk Score (R) = Likelihood (L) × Severity of Impact (S)
Scored from 1 (Negligible) to 5 (Extreme)
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step 3: analyze risks
Severity of Impact
RISK MATRIX Negligible (1) Minor (2) Moderate (3) Major (4) Extreme (5)
Almost certain (5) Moderate 5 High 10 Very high 15 Extreme 20 Extreme 25
Likely (4) Moderate 4 Moderate 8 High 12 Very high 16 Extreme 20
Likelihood
Possible (3) Low 3 Moderate 6 Moderate 9 High 12 Very high 15
Unlikely (2) Very low 2 Moderate 4 Moderate 6 Moderate 8 High 10
Rare (1) Very low 1 Very low 2 Low 3 Moderate 4 Moderate 5
Risk Score (R) = Likelihood (L) × Severity of Impact (S)
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step 3: analyze risks
Very low - low risk • Managed according to standard response protocols
(1-3) • Routine control programs and regulation
Moderate risk • Roles and responsibility for the response must be specified
(4-9) • Specific monitoring or control measures required
• Senior management attention needed: may be a need to establish command
High risk and control structures
(10-16) • Range of additional control measures will be required some of which may have
significant consequences
• Immediate response required
Very high - Extreme risk
• Immediate senior management attention needed
(17-25) • Implementation of control measures with serious consequences is highly likely
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step 3: analyze risks
Root Cause Analysis (RCA)
o A systematic method to find underlying
causes of adverse events
o Aims to implement effective changes
and prevent recurrence
o Brainstorming with relevant, knowledgeable
team members is the best approach
“Above the surface, you can see the symptoms of the problem
Dig deeper, you find the root cause of the problems”
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step 3: analyze risks
Root Cause Analysis (RCA) (cont.)
o Reactive RCA: Conducted after an undesired event or incident has
occurred (post-loss approach)
EVENT !! RCA EVENT !!
o Proactive RCA: Analyzes potential risks or weaknesses in systems
before an event happens (pre-loss approach) - based on evidence
and risk anticipation
RCA EVENT !!
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step 3: analyze risks
Root Cause Analysis (RCA) (cont.)
Focuses on systems and processes
Starts from each event, step, or point in the process, and connects it
to organizational-level contributing factors
Investigates by repeatedly asking “Why ?”
Seeks out systemic or process-level changes that are feasible
A good RCA provides a comprehensive analysis - covering human factors,
system/process issues, risk points, and opportunities for improvement
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step 3: analyze risks
Why-Why Analysis
Root Cause Analysis (RCA) : Tool
Ishikawa diagram
PROBLEM
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step 3: analyze risks
Root Cause Analysis (RCA) : Tool
5M1E
Ishikawa diagram
• Man : Workers, employees, or personnel
• Machine : Machinery or equipment
• Material : Components, or consumables used
• Method : Work procedures or operating
processes
• Measurement : Inspection, testing, calibration,
or data collection methods
• Environment : Physical conditions and
workplace atmosphere
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step 3: analyze risks
Why-Why Analysis
Root Cause Analysis (RCA) : Tool
o Ask "Why ?" repeatedly (typically 5 times)
until the underlying cause is revealed
o Focuses on cause-and-effect relationships
PROBLEM
o Helps avoid blaming individuals and instead
improves processes
o Commonly used in quality improvement, safety
investigations, and process analysis
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step 4: evaluate risks
The purpose is to prioritize risks based on their risk analysis score
Helps decide which risks need treatment
Determines the type or mode of treatment required
Evaluate risks step 4
Accept the risk Treat the risk step 5
Does not mean the risk is unimportant
May be accepted for various
reasons e.g. risk level is very low,
Controlling Transferring Avoiding
no available treatment option the risk the risk the risk
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step 5: treat/manage risks
Risk Treatment (Also known as Risk Reduction or Risk Mitigation)
o The decisions in risk treatment should be consistent with the defined
internal, external and risk management contexts and taking account of
the service objectives and goals
o Plan should include :
Proposed actions Person(s) responsible
Resource requirements Timeframes
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step 5: treat/manage risks
• Redesign systems/processes to reduce risk
Controlling the risk
• Lower the likelihood and/or impact of the risk
• Involves shifting or sharing risk to another party
Transferring the risk • Methods include: contracts, insurance,
outsourcing, joint ventures
• Involves not proceeding with activities that
Avoiding the risk carry unacceptable risk
• Choosing a safer alternative
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monitor and review
Monitoring and reviewing are key parts of the risk
management cycle
o Ensure that actions taken are effective and sustained
o Sources of monitoring data : incident reporting, clinical audit indicators,
patient tracers, safety rounds, patient complaints, satisfaction surveys,
staff complaints, medical records
Residual Risk = Total Risk – Controls
o Often not feasible to eliminate all risks completely
Goal : reduce risk to an acceptable level
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take home messages
Risk is inevitable in healthcare due to complex systems, time pressure, and high
expectations—but it can be managed
Five key steps in risk management
1. Establish the context – understand clinical and organizational environment
2. Identify risks – use reports, audits, and patient data
3. Analyze risks – assess causes, controls, and calculate risk score (R = L × S)
4. Evaluate risks – prioritize based on risk level (Low/Moderate/High)
5. Treat/manage risks – choose to accept, control, transfer, or avoid
Monitoring & review is essential to ensure effectiveness and continuous
improvement
R i s k M a n a g e M e n t i n H e a lt H c a R e page 31
reference
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tHank YOU fOR YOUR attentiOn
anY qUestiOn ?