Transcript Slide 1

How Bad?
What Can Go
Wrong?
Is there a Need
for Action?
How Often?
Task 1 – Planning the
Risk Assessment
Stage
Task 22--Meeting
Meeting
Preparation
Task 3 – Risk
Assessment Meeting
Task 4 – Review and
Follow-up
Example of Top Level Activity Mapping
Acute Admissions
Risk Assessment of
Patients on Wards
Planned treatment
(e.g. taking blood
samples)
HaN Team arrival
and handover from
Day team
Handover to Day
team and HaN Team
departure
Bed Management
Treatment of
patients needing
unscheduled care
Example of Second Level Activity Mapping
(Treatment of patients needing unscheduled care)
Ward nurse
identifies and
assesses patient in
need of treatment
Ward treatment
Bleep management /
HaN Team
assessment and
resource allocation
HaN Team
assessment
HaN Team treatment
resource allocation
Step 1 - Select activity to assess
Step 2 - Describe activity
(Document in top section of log sheet)
Step 3 – Identify relevant hazards
(Record in log sheet column 2)
Step 4 – Select relevant hazard to assess
Step 5 – Identify causes, patient safety
consequences and control (Record in log
sheet columns 3, 4 & 5)
Step 6 – Assess hazard’s risk and
determine the need for action
(Record in log sheet columns 6, 7 & 8)
Step 7 – Develop recommendations and
re-assess risk
(Record in log sheet columns 9, 10,11 and
12)
Step 8 – next
Another hazard?
No
Yes
Step 9 - Another
Activity?
No
Assessment complete
Medical Physics
Department
Medical records
Bed Management
A&E
O&G
Equipment
Library
Internal
administrative
Ambulance service
Pharmacy
Diagnostic
services
(X-ray,
pathology)
Internal
(Clinical
HaN
Solution
External
Mental Health Trust
ITU
Paediatrics
Theatres
Day Shift Teams
n
HaN Team receive
handover from day
staff
Bed management
Emergency
admissions
Bleep management
Inpatient
unscheduled care
Routine / planned
care
Handover to day
staff
Hospital at Night Risk Assessment Record Sheet – Activity: Handover from Day to Night
Date of Assessment: 14th January 2005
The exchange of information relating to patients identified as likely to be in need of additional or
extraordinary care during the night. The current bed status and work load is also discussed.
Hospital: Anon Hospital
Activity
Activity description:
Activity
No:
1
Inputs: Clinical information on patients, bed status and clinical workload.
Outputs: HaN team know which patients need specific observation, treatment, investigations and delivery plan
Resources (people, equipment, etc.): Day and night medical and elderly teams; meeting place for handover; protected time for
handover, PAS, bed management information.
Controls: Patient assessment tools; protocol (s); rota(s) and information proforma.
ID #
What could go
wrong?
Causes?
Consequences?
Controls?
Risk
*
Ranking
C L R
Recommendations?
Risk
*
Ranking
C L R
Figures used in Introductory
slides (HaN Risk Assessment
Guide)
Acute Admissions
Risk Assessment of
Patients on Wards
HaN Team arrival
and handover from
Day team
Planned treatment
(e.g. taking blood
samples)
Bed Management
Treatment of
patients needing
unscheduled care
Handover to Day
team and HaN Team
departure
Example of Second Level Activity Mapping
(Treatment of patients needing unscheduled care)
Treatment of
patients needing
unscheduled care
Ward nurse
identifies and
assesses patient in
need of treatment
Ward treatment
Bleep management /
HaN Team
assessment and
resource allocation
HaN Team
assessment
HaN Team treatment
resource allocation