Transcript risk management - MDU

Aim of programme

to apply the principles of risk management to
practical situations and relate these to personal
experiences
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to improve the quality of care by implementing
initiatives to remedy deficiencies in the service
provided.
Harvard Medical Practice Study
New England Journal of Medicine 1991
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3.7% patients suffered an
adverse event
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Of these 13% died
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58% events related to system
errors
Summary of New Complaints Procedure
(1998, 9/12 period)
MDU experience
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Failure or delay in diagnosis most common
reason (28%)
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24% of complaints made after bereavement
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Non-clinical issues accounted for 34% of
complaints
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10% of complaints related to attitude
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93% settled at L.R.
MDU Settled Claims Against
UK GPs
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Failure to diagnose
Medication error
Pregnancy including labour
Minor surgical procedure
Other
- 51%
- 26%
- 13%
- 7%
- 3%
MDU Claims Settled
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Quality of medical care -
7%
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Medical record issues -
60%
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System failures-
33%
MDU complaints study 1999
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33% complaints were due to failures in
systems, procedures and communication
e.g.
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rudeness/attitude staff or doctor
administration problems
prescription problems
communication
Clinical Governance
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Clinical risk management
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Complaints procedures
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Adverse incident reporting
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Clinical audit
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Evidence- based practice
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Whistle blowing
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Performance review
RISK MANAGEMENT
A careful examination of what
1. could cause harm
2. its significance and
3. what precautions are needed to eliminate the risk
or reduce it to an acceptable level
Risk Management Benefits
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for patients
–
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improved quality of care and service
enhanced patient safety
confidence in the service
for health care professionals
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protection of confidence and reputation
quality procedures and staff involvement
decreased numbers of complaints and claims
The four principles of risk
management
1.
Identify the risks – what’s likely to go wrong?
2.
Assess the risk – what are the chances of it going
wrong, what could happen, does it matter?
3.
Reduce/eliminate the risk – what can you do about it
4.
Cost the risk – what are the costs of getting it right v.
the cost of getting it wrong?
Risk Management Techniques
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Complaint handling
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Risk assessment
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Staff awareness/training
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Protocol and guidelines monitoring
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Good medical records
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Adverse incident reporting
Risk Areas
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Staff - especially locums
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Organisation
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adequate staffing
regular guideline review
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Communication
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Consent
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Record keeping
Clip 2 – Morning Surgery
Identified Risks
Breaches of confidentiality – front desk/reception
area
etc.
Health and safety issue.
Lack of systems.
Phone call interruptions.
Verbal requirements regarding nurse visit.
Inappropriate roll/responsibilities of receptionist.
What action do you suggest the practice takes in order to
avoid/minimise these risks (in priority order)?
Clip 3 – Test Result / Minor Surgery
Identified Risks
Dealing with smear results.
Aseptic techniques.
Lack of chaperones.
Unreasonable patient request.
Lack of informed consent.
Disposal of clinical waste/needles.
What action do you suggest the practice takes in order to
avoid/minimise these risks (in priority order)?
Clip 4 – Home Visit
Identified Risks
Examination.
Response to collapsed patient.
Communication regarding hospital admission.
Communication with mother.
Dealing with request for repeat prescription.
Dealing with aggressive patient.
What action do you suggest the practice takes in order to
avoid/minimise these risks (in priority order)?
Aims of Assessment
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Improve patient care
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Ensure safe standards of practice
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Ensure patient/staff safety and well being
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Decrease the number of complaints and claims
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Lessen the stress associated with litigation
The MDU’s risk management
pack
Part one Communication
How to use it
Each part contains:
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Case history examples
Checklist
Reference sections
Action plan
Score/evaluation sheet
How to complete
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Team approach
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set aside protected time
read questions and reference section
undertake the review (‘yes’ or ‘no’
answers)
consider action needed
complete action plan
complete the anonymised answer sheet
return sheet to PCG offices
Scoring system
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Yes - undertaking the activity
No - area needs review
Score 3 = essential
Score 2 = important
Score 1 = good practice