Transcript Building a safer NHS – the work of the National Patient

Risk Assessment
Dr Mike Rejman
Risk Assessment Adviser
1
Why do Accidents Happen?
2
Why do Accidents Happen?
3
How do Accidents Happen?
Organisation and processes
- Deficiencies
Prior conditions - basic causes
& contributory factors
“Unsafe” acts - active
failures (SRK errors)
Multiple
Defences
Patient
Safety
Incident
4
Understanding the Problem
• ~ 80%
of accidents are attributable to
human factors, at the individual level, the
organisational level, or more commonly
both
• This is a conservative figure and is
irrespective of domain
• To manage this we need to identify and
understand the risks (causes and
contributory factors)
• Without this we can’t put appropriate
remedial action in place
5
Seven Steps to Patient Safety
1. Build a safety culture
2. Lead and support your staff
3. Integrate your risk management activity
4. Promote reporting
5. Involve patients and the public
6. Learn and share safety lessons
7. Implement solutions to prevent harm
6
Step 3 - Integrated Risk Management
•
All risk management functions and information:
– patient safety,
– health and safety,
– complaints,
– clinical litigation,
– employment litigation,
– financial and environmental risk
•
•
Training, management, analysis, assessment and
investigations
Processes and decisions about risks into business
and strategic plans
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Risky Jobs
1
8
Risky Jobs
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Risk Assessment by Donald Rumsfeld
As we know,
There are known knowns.
There are things we know we know.
We also know there are known unknowns.
That is to say
We know there are some things we know we
do not know.
But there are also unknown unknowns The ones we don’t know we don’t know.
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The Accident Iceberg
1
10
30
600
accidents
serious incidents
incidents
near misses
& hazards
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Prior Indicators of Risk
• Challenger Space Shuttle
– evidence of seals shrinking
in cold temperatures, but
political pressure to launch
• Columbia Space Shuttle
– long-standing problem with
foam falling off (for 9 years)
– even after Columbia disaster,
a minority report noted at
least 3 crucial issues not
actioned
– this endangered Discovery
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Poor Design and Labelling
13
Poor Design and Labelling
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Identifying Areas of Risk
• Retrospective – learn lessons
– Accidents and incidents,
– Root Cause Analysis
• Prospective – anticipate issues
– Reporting systems, near misses, reported
hazards
– Prospective Risk Assessments, (proactive
hazard assessment)
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Some Risk Assessment Methods
•
•
•
•
•
(H)FMEA
– (Healthcare) Failure Modes
and Effects Analysis
HACCP
– Hazard and Critical Control
Points
HAZOPS
– Hazard and Operability
Studies
PRA
– Probabilistic Risk
Assessment
SWIFT
– Structured ‘What If’
Technique
HRA Techniques
• HEART
– Human Error Analysis and
Reduction Technique
• THERP
– Technique for Human Error
Prediction
• SHERPA
– Systematic Human Error
Reduction and Prediction
Approach
• GEMS
– Generic Error Modelling System
• IDEAS
– Influence Diagram Error
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Analysis System
Risk Assessment Methods
• There are a great many methods
• Most were developed in safety-critical industries
other than healthcare, only a few have been
adapted to healthcare, with mixed success
• Problems over
– some quantitative, some qualitative
– whether they can combine factors or only treat them
independently,
– issues over ‘number’ generation
– few experimental comparisons, validation, or guidance
– some very resource intensive
• Which one to use?
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Risk Assessment Methods
NPSA is developing two approaches to the
issue –
• (i) Patient Safety Research Fund – longer term
research to identify the best methods for
healthcare and adapt methods if necessary. Will
take 2+ years to produce a toolbox
• (ii) ‘Fast track’ pragmatic approach to produce
guidance in the short-term
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Risk Assessment’s Four Basics
Questions
What could
go wrong?
How bad
could this
be ?
How often?
Is there a
need for
action,
if so what?
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Lead to Four Management Options
•
•
•
•
Terminate
Treat
Tolerate
Transfer
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SWIFT
• Structured ‘What IF’ checklisT
• Good technique for considering both human and
organisational factors, as well as equipment
factors, that may affect safety
• Structure
• Identification driven by:
– Question driven
• What-if ………?
– Checklist
• Best done using a multi-professional group
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Risk Assessment Flow Diagram
Australian/New Zealand model
Establish the Context
• Risk assessment is a
“PROCESS”
Analyse Risks
Likelihood
Consequences
Level of Risk
Evaluate Risks
Accept
Risks?
Monitor and Review
Risk Assessment
• Aid to decision making
Communicate and Consult
• Helps to determine if
systems, facilities or
activities are acceptable
Identify Risks
yes
no
Treat Risks
22
Record Sheet
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Risk Matrices
Likely
Medium
Medium
High
High
Medium
High
High
High
High
High
4 Catastrophic
Public: Fatalities possible
Personnel: Fatalities likely
Environment: Large adverse impact
Equipment: Operations severely
disrupted: some units a total loss
3 Very serious
Public: Injuries possible: major nuisance
Personnel: Serious injuries/disabilities possible
Environment: Moderate adverse impact
Equipment: Operations disrupted:
damage extensive but repairable
2 Serious
Public: Minor nuisance: no injuries
Personnel: Minor injuries likely
Environment: Minor adverse impact
Equipment: Minor damage and/or
moderate downtime
1 Minor
Public: No effects
Personnel: Minor injury possible
Environment: Contained release*
Equipment: Minimal disruption to plant
operations
Urgent
2 Improbable
Unlikely to occur during
the life of the plant (up to
50 years)
1 Highly improbable
Event occurs rarely, if
ever, worldwide
High Priority
Medium Priority
Low Priority
No Action Required
Probable
Low
Medium
Medium
High
High
Possible
Low
Low
Medium
Medium
High
Severity
Catastrophic
Unlikely
Very Unlikely
Almost Impossible
Example Risk Matrix
Low
Low
Low
Minimal
Low
Low
Low
Low
Low
Minor
Low
Medium
Low
Medium
Medium
Low
Low
Moderate
Major
Consequence Class
Catastrophic
Frequency
Likelihood Class
* No impact to air, water, soil, treatment plant or other process units.
Medium
High
High
Possible
Low
Medium
High
Unlikely
Low
Low
Medium
Likely
Example Risk Matrix
Minor
Moderate
Major
Consequence Class
CONSEQUENCES
0 - Negligible
1 - Minor
2 - Moderate
3 - Serious
4 - Major
5 - Critical
Key
Major
Severe
Minor
Frequent
6
4
24
Probable
5
20
15
10
5
Occasional
4
16
12
8
4
Remote
3
12
9
6
3
Improbable
2
8
6
4
2
Incredible
1
4
3
2
1
Intolerable
(high priority)
Likelihood Class
• Used for:
– Qualitative
assessment of
the level of risk
from an event
• Commonly used
in risk
assessments
• Found in many
forms
Very Likely
4 Frequent
3 Infrequent
Likely to occur more
Likely to occur more than
often than once per year once during the life of the
plant (up to 50 years)
FREQUENCY
CONSEQUENCE
Impossible
0
0
0
0
0
0
0
No
Risk
3
18
2
12
1
6
Tolerable
(medium priority)
Rare
1
0
1
2
3
4
5
Low
Risk
Negligible
(low priority)
LIKELIHOOD
Unlikely
Moderate
2
3
0
0
2
3
4
6
6
9
8
12
10
15
Moderate
Risk
Likely
4
0
4
8
12
16
20
Significant
Risk
24
Certain
5
0
5
10
15
20
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High
Risk
• Two dimensions
– Consequence
• (Also commonly
called impact or
severity)
– Likelihood
• (Also commonly
called frequency or
probability)
• How to use
– Define for a risk:
• Its consequence
• Its likelihood
– Read off the risk level
Frequency/Likelihood/Probability
Risk Matrix
Risk
Consequence / Severity / Impact
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• Identification of hazardous
event/scenario
• Determining the risk using
a risk matrix
– Assessment of the
event’s/scenario’s
consequence
– Assessment of the
event’s/scenario’s
likelihood of
occurrence
– Determination of risk,
(plotting scenarios on
the risk matrix)
• Risk evaluation and
decision making
Likelihood
How to Use a Risk Matrix
Greater than one in ten
per patient year
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Medium
High
High
High
High
One in ten to one in a
hundred per patient year
6
Medium
Medium
High
High
High
One in a hundred to one
in a thousand per patient
year
5
Low
Medium
Medium
High
High
One in a thousand to
one in ten thousand per
patient year
4
Low
Low
Medium
Medium
High
One in ten thousand to
one in a hundred
thousand per patient
year
3
Low
Low
Low
Medium
Medium
One in a hundred
thousand to one in a
million per patient year
2
Low
Low
Low
Low
Medium
Less than one in a
million per patient year
1
Low
Low
Low
Low
Low
C
D
NPSA’s Patient Safety Risk
Matrix
A
B
Negligible /
Very Low
Low
(Minimal
Harm)
Moderate
Severe
(Short Term
(Long
Harm)
Term/Perm.
Harm)
Consequence
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E
Fatality
(one or
more)
Likelihood
One in a thousand to
one in ten thousand per
patient year
4
Low
Low
Medium
Medium
High
One in ten thousand to
one in a hundred
thousand per patient
year
3
Low
Low
Low
Medium
Medium
One in a hundred
thousand to one in a
Assessment
of the
million per patient year
2
How to Use a Risk Matrix
•
event’s/scenario’s
consequence
than one in a
– May beLess
a
range
of
million per patient year
possible outcomes
– If possible chose
outcome
which is of
NPSA’s Patient Safety Risk
regular concern
Matrix
– (Otherwise assess risk
for different outcomes)
Low
Low
Low
Low
Medium
For example if the consequence of the event/scenario
being assessed is the long term disability of a patient,
then the consequence class is “D, permanent harm”
1
Low
Low
Low
Low
Low
A
B
Negligible /
Very Low
Low
(Minimal
Harm)
C
D
Moderate
Severe
(Short Term
(Long
Harm)
Term/Perm.
Harm)
Consequence
E
Fatality
(one or
more)
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• Assessment of the
event’s/scenario’s
likelihood
– Note that the likelihood
is for the outcome
being considered
– Common error is to
match event likelihood
with worst case
outcome which only
happen in a minority of
the event outcomes
Likelihood
How to Use a Risk Matrix
For example, for the
event/scenario
Medium
High resulting
High
in long term disability of
a patient ( consequence
class “D, permanent
harm”, it could be
Medium
Medium
assessed
for any High
patient the likelihood of
this happening is in the
range 1 in 1,000 to 1 in
per year. Giving
Low10,000Medium
Medium
the likelihood class of 4
Greater than one in ten
per patient year
7
One in ten to one in a
hundred per patient year
6
One in a hundred to one
in a thousand per patient
year
5
One in a thousand to
one in ten thousand per
patient year
4
Low
Low
Medium
Medium
One in ten thousand to
one in a hundred
thousand per patient
year
3
Low
Low
Low
Medium
One in a hundred
thousand to one in a
million per patient year
2
Low
Low
Low
Low
Less than one in a
million per patient year
1
Low
Low
Low
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Low
A
B
C
D
High
High
High
How to Use a Risk Matrix
Likelihood
• Determination of risk
– Plot scenario on the
risk matrix
Greater than one in ten
per patient year
7
Medium
High
High
High
High
One in ten to one in a
hundred per patient year
6
Medium
Medium
High
High
High
One in a hundred to one
in a thousand per patient
year
5
Low
Medium
Medium
High
High
One in a thousand to
one in ten thousand per
patient year
4
Low
Low
Medium
Medium
High
One in ten thousand to
one in a hundred
thousand per patient
year
3
Low
Low
Low
Medium
Medium
One in a hundred
thousand to one in a
million per patient year
2
Low
Low
Low
Low
Medium
Less than one in a
million per patient year
1
Low
Low
Low
Low
Low
C
D
NPSA’s Patient Safety Risk
Matrix
A
B
Negligible /
Very Low
Low
(Minimal
Harm)
Moderate
Severe
(Short Term
(Long
Harm)
Term/Perm.
Harm)
Consequence
E
Fatality
(one or
more)
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Risk Evaluation and Decision Making
• The risk classes help drive risk mitigation decision making
• Common approach:
– Where the risk is assessed as:
• “Low”
– Evaluate as tolerable
– No risk mitigation recommendations needed
• “High”
– Evaluate as intolerable
– Risk reduction is required - aim to reduce
medium or low
• “Medium”
– Evaluate as tolerable if ALARP demonstrated
– Practical and cost effective recommendations to30
reduce risk needed
For Example - IT Systems
• Introducing IT systems can greatly increase
capacity AND help eradicate certain errors
BUT
• Unless systems are carefully designed to take
account of human factors, they can actually
increase errors and even introduce new ones,
with catastrophic consequences
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New Technology in Airbus 320
• ‘Glass cockpit’ and ‘fly by wire’ state of the art
technology
• Multifunction displays with many ‘pages’ some of
which are remarkably similar
• Operator awareness issues - leading to the
introduction of a new error - ‘mode error’
• 87 people died in a crash at Strasbourg
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‘New’ Error
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Results from NPSA Funded Study on GP
IT Systems (University of Nottingham)
• Allergy alert may not be generated
• Hazard alert generated every third prescription
– Single keystroke to over-ride alert
– No audit trail
• Not all safety functionality activated (e.g. contraindications)
• Hazards generated by drop-down menus (wrong
selection made – awareness)
• GPs unsure of safety functionality on systems
– Some think functionality is present when it isn’t (e.g.
contra-indications)
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Risk Assessment
To ensure safe operation …
Systems and Processes need:
• To be well designed (human factors) and
thoroughly risk assessed
• To be more intuitive
• To make wrong actions more difficult
• To make correct actions easier (telling
people to be more careful doesn’t work)
• And it should be easier to discover error 35
Hospital at Night (HaN) Risk
Assessment Guide
• Presents an approach to
risk assessing Hospital
at Night solutions
• Available on the NPSA
web site
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