Practice points
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Risk
ReviewRisk management in obstetrics
Section snippets
Definition
Risk management is the systematic identification, assessment and evaluation of risk. It can improve the quality of care, and develops safe systems of care that minimize adverse events for patients and staff. Risk management can be reactive (e.g. in response to a serious incident or a complaint), pro-active (e.g. establishment of a risk register or an assessment of national guidelines/reports) or preventative (e.g. ensuring adequate training and staffing levels).
Healthcare professionals should
Application
Increasing emphasis has been placed on risk management and clinical governance, with clinicians’ knowledge of these subjects being assessed in job interviews and included in postgraduate training and examinations.
The application of risk management is seen at all levels within an NHS hospital trust.
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Senior management may be concerned with the local strategy for infection control in a department, and its possible effect on unit closure if an epidemic (e.g. avian flu) arises.
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A multidisciplinary
Patients and staff
The effect of risk on patients can range from minor effects to severe disability or even death. There are also the unquantifiable effects such as the psychological impact and loss of faith and trust in the healthcare system. Such effects may be longlasting and influence how the individual uses the healthcare system in the future.
Healthcare professionals are also affected by risk. Staff can become:
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disillusioned with their careers
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demotivated in the workplace
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demoralized and at higher risk of
Evolution of risk management
Several reports have been instrumental in developing risk management over the last decade. In 2001, “An organisation with a memory” highlighted the need to learn from clinical error. The NPSA was established in 2001, with a remit to develop a national approach towards reporting incidents and learning from them. This included development of a national database for:
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reporting patient safety incidents
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distribution of safety alerts
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formulating solutions to identified risks
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Internet training for root
Clinical Negligence Scheme for Trusts (CNST)
After crown indemnity was removed (whereby the NHS centrally funded all claims), it became clear that in some financial years, some trusts (and in turn their patient population) may suffer severe financial embarrassment if there were several high-paying claims (often obstetric in origin). The CNST was set up to allow trusts to pool their claims/risks, and with each trust paying a proportion of its turnover into a common pot, high and low claims were balanced out so no single trust would suffer
Risk management process
The risk management process can be viewed as a systematic approach to dealing with a sequence of questions that aim to reduce risk. See box C. For example when looking at what could go wrong? Risk identification is required. Understanding the chances of it going wrong again and what would be the impact, is looked at by risk analysis and evaluation. When considering minimising the chances of risk happening or mitigating damage from such risk, risk treatment is required. The cost of prevention is
Risk identification
Risk is usually identified from incident reporting (using ‘trigger lists’ (see Table 4 or unusual events), complaints, or internal investigations of major adverse incidents. These three sources are familiar to those working in clinical areas, and may be grouped as internal sources. Proactive assessment of new care pathways or guidelines should identify risks and seek to eliminate them (e.g. guidelines should be reviewed by a multidisciplinary team to avoid errors).
Risk assessment in each
Incident reporting system
Clinical areas should have an anonymous system to report risk incidents. Trigger lists categorize incidents into maternal, fetal and organizational. These lists should be easily accessible in the clinical areas, and healthcare professionals should be aware of their contents. A trigger list compiled by the Royal College of Obstetricians and Gynaecologists is shown in Table 4. A multi-professional risk management team reviews the reports and assesses if a detailed analysis is required. In a
Risk register
A risk register is a centrally held ‘live’ document that should contain all the risks identified by a maternity unit and the trust. The register can be populated from incidents, complaints, national alerts and proactively looking for problems. These items should be graded according to how high the effect of the risk is (financial, media exposure, patient harm) and the likelihood of them occurring. The death of a neonate from MRSA is of moderate cost, high exposure in terms of bad publicity, but
Analysis and evaluation of risk
“What we call experience is often a dreadful list of ghastly mistakes.” J Chalmers da Costa (1863–1933).
People do not intend to commit errors. The ethos and training of medicine is based on primum non nocere (firstly, do no harm). It is not productive to focus only on the individual who was involved in an incident; the entire system must be analysed. This is known as a ‘systems view’ as opposed to a ‘person-centred view’.
Understanding medical error and particularly the human factor components
Incident analysis
After an incident has occurred, reproducible systems-approached analysis can be employed to investigate the event. The aim is not solely to establish what went wrong, but to identify contributory factors and pathways that may be altered to minimize the chance of event reoccurrence and maximize delivery of safe healthcare. Various approaches have been used to achieve this analysis, such as root cause analysis (RCA).
RCA originated in industry and uses a series of tools to investigate and analyse
Training, induction and competence
A prerequisite of good medical care is that the clinician is trained in the procedure he is undertaking and competent at carrying it out. We have moved from the concept of ‘see one, do one, teach one’ where individuals were not formally trained and their competence was not formally assessed. It was possible for a doctor to be expected to do a breech vaginal delivery despite having never seen one (or practised on a simulator). In the twenty-first century, middle-grade obstetricians are expected
Conclusions
Risk management is an approach to clinical care that actively searches for weaknesses in the system and attempts to correct them before harm comes to patients or staff. Risk management is often reactive rather that proactive, but at least this prevents errors being repeated. Done well, risk management involves all members of staff, is seen as a learning process rather than a means of looking for fault, and improves outcomes for everyone involved in health care at every level.
Further reading (6)
An organisation with a memory: report of an Expert Advisory Group on learning from adverse events in the NHS
(2000)Standards for better health
(2004)Understanding adverse events: the human factor
There are more references available in the full text version of this article.
Cited by (5)
The medicalisation of childbirth
2017, The Social Context of BirthRisk management in the NHS: Governance, finance and clinical risk
2012, Clinical Medicine, Journal of the Royal College of Physicians of LondonApplying root cause analysis to improve patient safety: Decreasing falls in postpartum women
2010, Quality and Safety in Health Care
“Those who do not remember the past are condemned to repeat it.” George Santayana (1863–1952)
Copyright © 2008 Elsevier Ltd. All rights reserved.