Medical Research Institute

Risk management tools

There are many tools that can be used for effective risk management as shown in the table.

Risk Management Tools
Risk management facilitation methods (flow charts, check sheets, etc)
Failure Mode Effects Analysis
Healthcare Failure Mode effects Analysis
Failure Mode Effects and Critically Analysis
Hazard Analysis and Critical Control Points
Hazard Operability Analysis
Preliminary Hazard Analysis
Barrier analysis and risk controls
Supporting statistical tools

Risk register

A risk register can be described as a log or repository of the various risk assessments and control performed within an organization. It is a dynamic document which enables the organization to understand its comprehensive risk profile. It provides a structure for collecting information about risks that will assist both in the analysis of risks and in decisions about whether or how these risks should be controlled, managed and monitored.

Risk control

Ideally all risk should be eliminated but in reality this is not possible. However, certain steps can be taken to minimize the likelihood of its occurrence, lessen its consequences and increase its detection. This can be done through the following:

Risk reduction

This is the main line of dealing with any risk in clinical practice. Risk reduction aims at preventing the risk from happening and either minimizing its harmful effects or preventing it from reaching the patient in case its occurrence could not be prevented.

Risk acceptance

If the risk cannot be totally eliminated and the consequences are minimum then it can accepted as part of practice, however, all involved should be made aware of such risk and trained to deal with such risk effectively in order to minimize any harm resulting from it.

Risk transfer

If the facilities and expertise available are limited then by transferring the service to another unit that is more equipped and trained the risk is minimized. This also applies to the involvement of insurance companies in the management of highly complex and costly treatments.

The following table is a summary of methods of risk control:

Risk Control

Avoidance	Identifying and implementing alternative procedures or activities to eliminate risk.
Contingency	Having a pre-arranged plan of action that will come into force as and when the risk occurs.
Prevention	Putting in place measures to stop a problem from occurring or having impact on a work area or organization.
Reduction	Taking action to minimize either the likelihood of the risk developing or its effects
Transference	Transferring the risk to a third party.
Acceptance	Tolerating the risk when its likelihood and impact are relatively minor, or when it would be too expensive to mitigate it.

Risk assessment

Risk assessment is formed of three steps. The first step is to identify the hazards (what may go wrong?). Second, to know what are the consequences of this risk and how often could this risk happen. Third, involves a decision regarding the need for further action to be taken against the specific risk based on quantitative or a qualitative description.

Hazard Identification (What may go wrong?)

There are several methods that can be used in identifying hazardous clinical processes that carry high risk to patient safety (see table below). Once a process is identified, it is mapped and broken down into its component steps. In doing so, the events that may lead to patient harm (hazards) can be further identified and related to each step.

Hazard identification

Adverse event reporting
Complaints and law suits
Medical records review
Observation of practice (work space and procedures performed)
Mortality and morbidity meetings
Patient and health care staff interviews
Patient safety organizations

Risk analysis (How serious and how often?)

Risk analysis is the estimation of the risk associated with the identified hazard. Each step of the chosen process is analyzed by answering the following three questions. First, what are the consequences of the event if it happens and second how often is it expected to recur and third how easily can it be detected?

In answering the first question the next consequence table can be used.

Consequence Rating

Descriptor	Impact
5 – Catastrophic	Death Continued ongoing long-term effects at time of discharge Many > 50: Vaccination error
4 – Major	Permanent injury Increase in length of hospital stay by > 15 days Moderate 16 – 50: Lost specimens
3 – Moderate	Semi-permanent injury Increase in length of hospital stay by 4-15 days Small 3 – 15
2 – Minor	Short term injury Increase in length of hospital stay by 1-3 days 1 – 2
1 – Insignificant	No injury No increase in hospital stay N/A

Other factors can be taken into account and integrated into the consequence table such as cost of the risk, impact on the service, impact on the organization, etc.

In answering the second question the following likelihood table can be used.

Likelihood Rating

Descriptor	Description
5 – Certain	Will undoubtedly happen / recur Expected to occur at least daily >50 percent
4 – Likely	Will probably happen / recur Expected to occur at least weekly 10-50 percent
3 – Possible	Might happen or recur occasionally Expected to occur at least monthly 1-10 percent
2 – Unlikely	Do not expect it to happen / recur but it is a possible it may do so Expected to occur at least annually 0.1-1 percent
1 – Rare	This will probably never happen / recur Not expected to occur for years <0.1 percent

In answering the third question the following detection table can be used.

Descriptor	Description
5 – Remote	Detection not possible at any point in the system 0-5 percent
4 – Low	Error rarely detected before reaching patient 6-39 percent
3 – Moderate	Error infrequently detected before reaching patient 40-74 percent
2 – High	Error frequently detected before reaching patient 75-94 percent
1 - Very high	Error will almost always be detected 95-100 percent

Risk evaluation (Do we need to do something?)

Risk evaluation considers the evidence presented through the previous step (risk analysis) and a decision is taken either to take action to control the risk if considered high enough or no action if the risk is considered low. In addition, risk evaluation can help safety teams prioritize a set of risks that have been identified thus facilitating the selection of the most significant ones for their treatment (risk control). There are two methods that can be used for risk evaluation

Risk Matrix

A risk matrix will plot risk consequence against risk likelihood to reach an estimate or grade for the risk. Each institution should decide on the level (grade) at which the risk is considered unacceptable and that necessary measures are needed. Furthermore, such a matrix can aid in deciding what management level should be involved in the risk control and how rapid should the response be.

The following risk table can be used to help reach a decision:

	Consequence
Likelihood	1 Insignificant	2 Minor	3 Moderate	4 Major	5 Catastrophic
5 - Certain	5	10	15	20	25
4 - Likely	4	8	12	16	20
3 - Possible	3	6	9	12	15
2 - Unlikely	2	4	6	8	10
1 - Rare	1	2	3	4	5

Risk	Low	Moderate	High	Extreme
	1-3	4-6	8-12	15-25

Criticality Index
The Criticality Index (CI) also known as the Risk Priority Number (RPN) is a numerical grading of the risk and can be used in prioritizing risks prior to the selection of the most significant ones for control. The CI can be calculated using the following formula:

CI = L X C X D

where

L: likelihood

C: Consequence

D: Detectability

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