ABC MEDICAL CENTER
Patient Safety Manual
SECTION:
EFFECTIVE DATE: October 1, 2006
SUBJECT:
Proactive Risk Assessment Policy
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Scope:
This policy applies to all direct and indirect patient care processes, departments, and
facilities of ABC Medical Center (ABC).
Objective:
To establish a comprehensive, proactive risk assessment process to evaluate the potential
adverse impact of direct and indirect patient care processes, buildings, grounds,
equipment, occupants, and internal physical systems on the safety and health of patients,
staff, and other people coming to ABC. This proactive risk assessment process is used to
identify, rate, and prioritize risks and or hazards. Based on this risk assessment, policies,
procedures, and controls may be put into place to manage the risks as appropriate to the
organization, with the intent of reducing them to the lowest possible level.
Policy:
ABC conducts proactive risk assessments to identify and evaluate the potential of adverse
impacts of direct and indirect patient care processes, buildings, grounds, equipment,
occupants, and internal physical systems on the safety and health of patients, staff, and
other visitors. Risk assessments are performed on identified hazards and proposed
changes to new or existing processes. Examples of proposed changes include automated
or manual work processes and equipment or other technology.
The goal of performing risk assessments is to reduce the likelihood of or mitigate the
impact of incidents or other negative experiences that have the potential to result in
injury, accident, or other loss to patients, visitors, staff, or assets.
It is important to understand that no process, activity, or system can ever be made
completely risk free. Some level of risk is always present. The concept of risk
assessment involves examination of the risks and making a determination as to what level
of risk is acceptable to the organization. With limited resources, the object of risk
assessment is to manage the risks in a prioritized fashion.
Ultimately, ABC’s leadership is responsible to determine the acceptable level of risk. If
the level of risk is determined to be unacceptable, the risk must be removed, controlled,
or reduced to an acceptable level for the process or activity to continue.
Results of the risk assessment process and other potential safety issues are reported and
discussed in the Patient Safety Committee (Patient Safety) meetings. In the Patient
Safety process, recommendations on management of the issue at hand are reached based
on the committee’s evaluation of the situation and the pertinent data. This information
may be used to create or revise policies, procedures, and practices, as well as develop
orientation and education programs and performance monitors.
© Critical Management Solutions, 2009
Procedure:
1. The first step of the risk assessment process involves identifying potential risks to be
the subject or target of the assessment process. Risks may be discovered as a result of
incident reports, near misses, and environmental tours which are used to uncover
environmental deficiencies, hazards, and unsafe practices. Potential hazards that are
identified and do not involve simple corrections are candidates for risk assessment.
Additional sources of potential risk identification may include:
 Issues reported to or identified by the Patient Safety Officer
 Observations by any staff member
 Published reports in the healthcare literature
 New regulatory issues
 JC Sentinel events alerts
 Product recalls
 Inspections from outside agencies, insurance carriers, consultants
 Internal events /Incident reports: injuries, accidents
 A staff member concern that is brought to the attention of their department
manager, the Patient Safety Officer, or any Patient Safety Committee member
 Any source that identifies a potential risk
2. The Patient Safety Officer will schedule departmental and area risk assessments by
determining if any areas not scheduled for an initial assessment in a given year have
had significant changes that would indicate the need to conduct a risk assessment in
that area.
3. Once a potential risk is identified, the Patient Safety Officer will present the issue for
discussion at the next Patient Safety Committee meeting.
4. The Patient Safety Committee will discuss the risk and if appropriate, appoint a risk
assessment team to analyze the risk and report their findings at the next Patient Safety
Committee meeting.
5. The Patient Safety Officer will train the risk assessment team members on the
proactive risk assessment process and how to conduct a proactive risk assessment,
including the assessment of risk, itself.
6. The risk assessment team will conduct an inspection of the department/area being
assessed for risk or observe the process being assessed for risk in action. The
members of the risk assessment team will individually document their findings on the
“ABC Proactive Risk Assessment Worksheet” (Attachment A). To determine the
appropriate score for each identified risk, the reviewer will consider information
obtained through a physical tour of the facility, review of annual incident and
accident statistics, review of at least the past twelve (12) months Patient Safety
Committee meeting minutes, hazard surveillance reports, interviews with department
heads, and on-unit interviews with a representative sampling of staff. A proactive
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risk assessment may require more than one visit. In the event there is significant risk,
visit frequency will be determined on an individual basis.
7. The risk assessment team members will then meet to compare their results and, using
multi-voting technique, agree on a single set of results for the risk assessment. The
team will determine the risk score based on the probability and impact on the
organization. The report will also include possible controls or other methods to
reduce the risk to the lowest possible level. The report is to include estimated costs
associated with the implementation of the suggested controls and the team’s
recommendations.
8. The risk assessment team findings will be presented at the next Patient Safety
Committee meeting and analyzed. If necessary the committee will make a
recommendation to Medical Center Administration on managing the risk reduction
and control implementation. Management of the risk can occur in several ways:
 Risk Reduction: Implement controls to reduce severity or probability.
 Transfer: Insure against the risk
 Avoid: Stop performing the process.
 Accept: Perform the process despite the risk
Using the Risk Assessment Matrix on the ABC Proactive Risk Assessment
Worksheet, the potential risk is assigned a score of 1 to 16. Scores of 1 – 4 are
considered “Low Risk” and are monitored and the risk re-assessed annually.
Potential risks with scores of 6 – 9 are defined as being “Medium Risk” and are
addressed by establishing controls to minimize this risk. “High Risk” areas or
processes receive scores from 12 – 16 points and are subject to immediate risk
reductions strategies and required action.
Only the leadership of the organization can make the decision to accept any level of
risk.
9. The Patient Safety Committee will review the risk assessment team’s report,
determine if the risk assessment is acceptable, and, if so, using Risk Assessment
Tracking System (Attachment B), define:
 The specific risk reduction strategies to be implemented;
 An accountable individual(s) to manage the implementation of the risk
reduction strategy;
 Timeframes for the implementation of each step in the risk reduction plan; and
 A process to monitor implementation of the risk reduction efforts.
 Whether any interim actions are indicated to mitigate the impact of the
identified risk while the risk reduction efforts are being implemented and, if
so, the specific nature of these interim actions.
The Patient Safety Committee will also specify the frequency with which they expect
reports from the responsible individual(s) on the implementation status of risk
reduction efforts.
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10. The Patient Safety Committee will also determine a schedule for a reassessment of
the identified risk to verify that risk reduction strategies were implemented and are
being followed. Frequent reassessment of the area or process will also continue until
necessary policies and procedures have been written, the area is in compliance with
policies, procedures, and appropriate regulations, and the Patient Safety Committee is
convinced that the risk level has been lowered to an acceptable level.
11. The Patient Safety Committee will assess whether an area that was considered high
risk in a previous year requires an annual proactive risk re-assessment or is now a low
or medium risk.
12. When a department/area or process has met the criteria to be lowered to an
acceptable level of risk, it will be moved onto the schedule of the Patient Safety
Rounds visits.
Should any situation(s) that constitute an imminent danger be discovered during the
course of the risk assessment, they will be reported immediately to the Patient Safety
Officer or designee and the appropriate department manager or designee for
appropriate follow-up action to resolve the identified issue(s).
Documentation of this risk assessment process will be found in the Patient Safety
Committee meeting minutes.
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ATTACHMENT A
ABC MEDICAL CENTER
RISK ASSESSMENT WORKSHEET
HAZARD/RISK:
_____________________________________________________________
Location of Hazard/Risk:
____________________________________________________
Potential Risk (Impact) if hazard is not addressed:
_____________________________________________________________
Means of Identification: __________________________________________________
_______________________________________________________________________
Assessment Team: _______________________________________________________
_______________________________________________________________________
Date of Identification: _____________ Date of Assessment: _________________
Description of Hazard:
(Attach additional sheets as necessary)
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ABC MEDICAL CENTER
RISK ASSESSMENT WORKSHEET
RISK ASSESSMENT MATRIX
RISK = PROBABILITY SCORE x IMPACT SCORE
Risk Element Description
Probability
PROBABILITY DEFINITIONS:
1
2
3
4
Not likely to ever occur
Possibly can occur in a year
Probably will occur in a year
Very likely within one year
Risk Score:
1-4
6-9
12 - 16
Impact
IMPACT DEFINITIONS:
1
2
3
4
Low Risk
Medium Risk
High Risk
Minor or no injury
Minor injury or illness
Severe injury/illness
Loss of life
Monitor and assess annually
Establish controls to minimize risk.
Immediate risk reductions strategies
and action required
SUBJECTIVE ASSESSMENT OF RISK:
RECOMMENDED RISK REDUCTION STRATEGIES OR PROPOSED
CONTROLS: (attach separate sheet as necessary)
Proactive Risk Assessment Policy
Risk Score
(P x I)
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ATTACHMENT B
ABC MEDICAL CENTER
PROACTIVE RISK ASSESSMENT
RISK REDUCTION TRACKING SYSTEM
Status as of: 2/5/16
Nature of Proactive Risk Assessment Conducted: ___________________________
Date Proactive Risk Assessment Conducted: ______________
Risk Assessment Team Lead/Responsible Individual: ______________________
Proactive Risk Assessment Team Members:
_____________________________
____________________________
_________________________
______________________________
____________________________
_________________________
______________________________
____________________________
_________________________
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Risk
Identified
Risk Level
Classification
(H/M/L)
Risk
Reduction
Strategy
Accountable
Individual
Timeframe for
Completion
Approvals:
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Current Status
of Risk Reduction
Strategy
Implementation
Interim Action(s)
to Mitigate Risk
(if Indicated)