Risk Management and Patient Safety

Risk management and patient safety

Risk Management is a process by which we identify factors which may prevent us from providing excellent, safe, efficient and effective care. Risk can occur in a variety of ways, for example as a result of changes in how or where we deliver services. The aim of risk management is to ensure these risks are identified early, assessed as to the best way to manage or control them and to reduce their effect.

At the heart of our services are our patients and part of this risk process includes ensuring that any areas where patient safety may be compromised or where something is identified that may have the potential to cause harm to patients, is managed. Identifying and reporting safety issues early ensures that the controls can be put in place to reduce the likelihood of those risks occurring again. When an outcome of care or a process is not as expected we investigate using a process called Root Cause Analysis to identify what happened and why so that we can put processes in place to improve safety.

To do this, the Risk Management and Patient Safety team work closely with clinical teams and other corporate areas to identify their risks, acting as a resource and providing advice and support on all aspects of risk management.

We also have close links with the Performance, Patient Experience, Complaints and PALS services. Sometimes these are the first areas which identify from patient and user feedback and internal monitoring that a system or process is not working well.

This joined up approach ensures that we have a direct link into patient experience as well as the broader governance, monitoring, audit and improvement processes within the Trust. The overall aim is to ensure that clinical and non clinical risks are managed appropriately to improve safety for patients, carers, staff and visitors.

Incident Reporting

Incident Reporting

Incident reporting is a key way by which we capture events that staff identify have the potential to cause harm or affect service delivery as well as actual events that occur. Each incident is graded to reflect the consequence of the event and the likelihood that it could happen again to produce a risk score between 1 and 25. The higher the score, the greater the assessed level of risk. This helps staff to prioritise the actions they need to take to reduce or control the risk and support the escalation and monitoring process to ensure the risk is managed properly.

The aim of an effective reporting system is to have the number of reports over time increasing, but the severity of the reported risks going down. This indicates that staff are risk aware and are spotting risks before they can cause harm.

Incident Investigation

Incident Investigation – Root Cause Analysis

On the rare occasion when a mistake is made or if a trend in reporting is identified, regardless of whether any harm was caused, an investigation called a Root Cause Analysis may be completed. This is a structured investigation technique, and provides an opportunity to look at the facts of the event that occurred and to find out why, working with the teams or staff involved to ensure all aspects of an incident is captured.

By finding out why an incident has occurred it ensures that lessons can be learned and action taken to reduce the risk of the incident occurring again.

Compliance and External Monitoring Requirements

Compliance and External Monitoring Requirements

In line with all NHS Trusts, NCH&C is a regulated organisation, registered with the Care Quality Commission to provide certain types of care. We are monitored for our compliance with good practice for Risk Management through the Risk Management Standards assessments managed by the NHS Litigation Authority and the national Information Governance Toolkit standards to ensure we keep the information we hold about you secure.

As part of this process, we have internal monitoring systems to enable us to check our progress against these national standards and to ensure that any changes required to improve compliance are completed.

Emergency planning

Emergency Planning

As part of a broader risk management role, the team also manages the Emergency Planning function within the Trust. The purpose of emergency planning is to ensure that all of our teams and services have business continuity plans in place to reduce any disruption to services in the event of a major incident occurring. The aim is to keep services running as far as possible as well as helping us to help keep you safe.

As part of this process, we have plans in place to manage a range of situations whether as a result of something which occurs internally, such as a local power failure, or a large scale event such as  flooding.

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