The objective of managing risk is to
understand, report, monitor and
minimise risks to patients and staff.
One of the most important aspects of
risk management is learning from mistakes
or near misses in order to reduce the risk
of them recurring.
October 2004
Risk Management
A Risk Management system will enable an
organisation and the people within it to identify,
report and understand what goes wrong in
patient care, learn from the experiences and
take appropriate action to ensure that it does
not happen again by sharing this knowledge.
Risk is the chance of an event happening that
may harm patients, their relatives, staff, and
possibly the Trust’s finances and/or it’s
reputation. Risk management is a systematic
programme of clinical and administrative
activities that are undertaken to identify,
evaluate and take actions in order to reduce
the risk of injury and loss. It involves:
identifying, analysing, handling and monitoring
of risks and learning from harmful events to
avoid their recurrence.
A Risk Management system will not eliminate
human error or the mistakes made under
pressure, but it will reduce the risk to a
minimum by ensuring safe systems are in
National Initiatives
National Patient Safety Agency (NPSA)
Is a special health authority formed in July
2001 after ‘Organisation with a Memory’ (DoH
2000) and ‘Building a Safer NHS for Patients’
(DoH 2001) were published.
These reports exposed the need to learn more
from things that go wrong and mobilised
patient safety in the NHS.
NPSA 7 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 and communicate with patients
and the public.
6. Learn and share safety lessons.
7. Implement solutions to prevent harm.
Risk Pooling Scheme for Trusts
The National Health Service Litigation Authority
(NHSLA) is established to indemnify NHS
Trusts in respect of both clinical negligence
and non-clinical risks. It manages both claims
and litigation and has established risk
management programmes against which NHS
Trusts are assessed.
Patient Concerns
Patient Concerns re safety
 Don’t kill me
 Don’t hurt me
 Don’t cover up mistakes
 Don’t make me feel helpless
 Don’t tell me you can if you can’t
Involve your patients, help them
 To reach an accurate diagnosis.
 Decide about appropriate treatment.
 Choose an experienced and safe provider.
 Ensure treatment appropriately
administered, monitored and adhered to
identify adverse events and take
appropriate action.
Charles Vincent & Angela Coulter (2002)
And when if things do go wrong…
 Actively involve your patients and family.
 Prioritise the need to tell patients when
incidents occur and provide them with
clear, accurate and timely information.
 Make sure patients and their family receive
immediate apology where it is due and are
dealt with in a respectful and sympathetic
way (7 Steps to Patient Safety).
Creating the Culture
The perfection myth - if people try hard
enough they will not make any errors.
The punishment myth - if we punish people
when they make errors they will make fewer
The best way of reducing error rates is to
target the underlying systems failures, rather
than take action against the individual member
of staff (NPSA 7 Steps to Patient Safety)
How to Create the Culture
 Consistency - ensure a standard
approach to Risk Management across the
 Policies – establish a system to ensure all
policies are accepted by all clinicians;
systematically disseminated and
 Communication - huge area of risk – Risk
Pooling Scheme for Trusts (RPST) aids
effective communication about risk.
 Education and feedback – for continuous
It is the duty of every employee to take
responsibility for the safety of themselves, their
patients and colleagues.
Every employee should comply with the risk
management requirements of the organisation
by assessing and managing risk and when
necessary bring it to the attention of their line
Individual responsibilities:
 Reporting incidents/accidents via the
Trust’s incident form that should be sent to
your line manager. See the ‘Incident Book’
yellow folder in your base.
 Assessing and reporting risks – being
proactive by bringing to attention areas of
risk that could cause harm to patients and
 Shared learning – teams meet and discuss
their experiences and that of others (e.g.
national issues from NPSA).
Some examples of why
things go wrong
Weak leadership
No coherent
Education and
research not valued
Weak systems
Poor information
Failures in
of Care
Defensive to
Lack of skills
Fortress mentality
Little collaboration
or networking
Bad team working
Poor motivation and
Ostrich mentality
Risk Areas
Clinical practice (delay in diagnosis).
Medico-legal issues.
Health and safety - including premises,
first aid, fire, VDUs, infection control,
sharps & waste, hazardous substances
and equipment (autoclaves, fridges,
nebulisers, sphygmomanometers, lasers,
Patient records/confidentiality.
Record keeping.
Patient experience and complaints.
What is a Risk Assessment?
A risk assessment is a careful examination of
what, in your work, could be a hazard.
This enables you to decide whether you have
taken enough precautions, or should do more
to prevent harm.
The aim is to make sure that no one gets hurt
or becomes ill.
The Five Stages of Risk Assessment
Step 1
Hazard means anything that can cause harm
(e.g. chemicals, electricity, machinery). Risk is
the chance, high or low, that somebody will be
harmed by the hazard.
Walk around your workplace and look afresh at
what could reasonably be expected to cause
harm. Concentrate on significant hazards that
could result in serious harm or affect several
Ask your colleagues what they think – they
may have noticed things that are not
immediately obvious.
Step 2
Don’t forget to consider:
 Trainees, new/expectant mothers, etc who
may be at particular risk.
 Cleaners, visitors, contractors,
maintenance workers, etc who may not be
in the workplace at all times.
 Members of the public.
Step 3
 Can I get rid of the hazard altogether?
If not, how can I control the risks so that
harm is unlikely?
 Try a less risky option.
 Prevent access to the hazard (e.g. by
 Organise work to reduce exposure to the
 Issue personal protective equipment.
 Provide welfare facilities (e.g. hand
Step 4
You must record the significant findings of your
assessment, e.g. “Electrical installations:
insulation and earthing checked and found
Keep the record for future reference.
You must also tell your employees about your
You must be able to show that:
 A proper check was made.
 You asked who might be affected.
 You dealt with all the obvious significant
hazards, taking into account the number of
people who could be involved.
 The precautions are reasonable, and the
remaining risk is low.
Step 5
If there is any significant change in your
workplace, or new equipment, review your
It is good practice to review your assessment
from time to time to make sure that your
precautions are still working effectively.
Definition of Incidents
Adverse incident: Any unfavourable event or
circumstance that results in a harmful outcome
of clinical care or therapeutic intervention.
Including property loss or damage.
Accident: Any unexpected event which results
in harm, personal injury or ill health e.g.
needlestick, fall.
Near miss: Any event or circumstance that
was prevented, so narrowly avoided injury or
harm, but if it had occurred could have had a
detrimental result.
Potential Risk: Anything that poses a threat to
people or service provision.
Significant Event: A noteworthy event (good
or bad) that is reported for the purposes of
sharing learning within the clinical team.
Further Investigation
Incidents with a high frequency or recurring
theme and those with high-risk ratings will
need more detailed consideration.
Root Cause Analysis (RCA)
The purpose of any investigation should be:
 Find out the full facts, with respect to the
sequence of events that led to the incident
 Determine what was managed well.
 Determine what, if anything, went wrong
and identify issues of concern.
 Identify the actions required to prevent
recurrence, and who can implement them.
Incident Reporting and
Significant Event Analysis (SEA)
All staff must report clinical and non-clinical
incidents via the Trust’s reporting system. This
information can then be used to reduce risk.
Significant Event Analysis includes recording
events (good and bad), followed by a
systematic peer review of the event, discussion
to identify what happened and share the
learning outcome within and outside the team.
NHS organisations use SEAs as one of the
ways to develop an open, transparent and
blame-free culture.
When errors occur it is usually the systems,
rather than the individuals, which are reviewed.
Independent Contractors should submit
quarterly reports on Significant Events to the
Clinical Governance Office.
Contributing Factors to Risk
Root Cause
All staff
for Risk
on Agenda
at Team
Risk Management References
The National Patient Safety Agency website:
The Healthcare Commission (CHAI) website:
The Health and Safety Executive website:
The National Health Service Litigation Authority
Your local Risk Management contact
Corporate Services Office
Bedford PCT
Gilbert Hitchcock House
21 Kimbolton Road
MK40 2AW
Tel 01234 795714 (switchboard)
Clinical Governance Team
Bedford PCT
Gilbert Hitchcock House
21 Kimbolton Road
MK40 2AW
Tel 01234 795714 (switchboard)
Direct Line
01234 795760