GOVERNANCE AND ACCOUNTABILITY IN HEALTHCARE

DR I NYANGU
SESSION 4
Risk management and patient safety
  Risk management refers to the
systematic identification and
assessment of risks to both
patients and staff.
RISK  The basic elements include:

MANAGEMEN
 Risk awareness
 Risk identification

T 


Risk assessment
Risk control
 Risk assurance

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  This reflects the ability to
understand situations that pose a
risk, to predict hazards and to
minimize those risks for patients,
staff and the wider public.
 Requires a culture that is open
RISK 
and honest
Barriers to developing effective

AWARENESS awareness include:

 Blame culture
 Apathy
 Fixation on issues
 Involuntary automaticity

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 Clinical risk can be identified
from several sources. Examples
include:

RISK  Clinical incident or patient safety

incident reporting

IDENTIFICATI 


Complaints and claims
Clinical audit

ON 


Mortality and morbidity statistics
National reports and patient
safety alerts

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  Risk assessments are undertaken
to estimate the consequences
and likelihood of a particular risk
being realized and can facilitate
RISK 
decision-making processes.
Assessment of risk exists at all

ASSESSMEN levels of healthcare from direct

patient care to board-level
strategic decision-making.
TS  Assessment can be carried out for
individual patients or for groups of
patients or an entire population.

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 Risk control is the process of
selecting, implementing and
monitoring measures taken to
modify risks within the
healthcare context. There are 5

RISK
recognized options for risk
control:
 Risk avoidance
CONTROL 


Risk prevention
Risk reduction
 Risk transfer
 Risk retention

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 This refers to the assurance that key
risks have been identified and are
being controlled at tolerable levels.
NHS hospitals are required to have in
place a system of controls for:
 clinical risks

RISK 


financial risks
organizational risks

ASSURANCE Risk registers should contain:

 identified risks
 types of controls
 who is responsible
 timeframes for action

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 Seven steps according to NPSA
(2004):
 Build a safety culture

MODELS
 Lead and support staff
 Integrate risk management
activity

FOR 


Promote reporting
Involve and communicate with

PRACTICE 
patients and public
Learn and share safety lessons
 Implement actions to prevent
harm

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 Systems and structures need to be in place.
Risks are involved at every stage of patient
care.
There must be thorough investigation of
incidents:
 Root cause analysis
 Chain of events

ORGANISATION  Tools e.g., the ‘fishbone’ diagram (NPSA,

2004)
 the patient
AL ASPECTS  the task
 the individual
 the team
 the environment
 organizational and management
factors

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  A patient, aged 84 with a history
of falls, was admitted via A/E with
respiratory problems for which he
was treated with IPPV. He was
taken directly to ICCU where he
was ventilated overnight. His
intubation was removed the next
morning, and he was
SCENARIO subsequently transferred to the
ward at 7pm. The ward was busy
but after visiting their relative, the
family asked for bedrails to be put
in place and this was carried out.
At 3am, the patient was found
lying on the floor and suffered a
fractured hip. He dies two days
later.

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What risk assessments should
have been carried out? DISCUSSIO
N
Should the bedrails have been QUESTION
placed on the bed – please justify S
your thoughts

What other risk avoidance

measures could have been
taken?

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Mr. Stanley Londborg is a 64-year-old man with a long-standing history
of a seizure disorder. He also has hypertension (high blood pressure)
and chronic obstructive pulmonary disease (COPD). He is no stranger to
the hospital because of his health issues. At home, he takes several
medications, including three for his COPD and three — levetiracetam,
lamotrigine, and valproate sodium — to help control his seizures. ADDITION
Mr. Londborg came to the emergency department (ED) last week
AL CASE
because he was wheezing and having trouble breathing. The physician
in the ED conducted a physical examination that yielded signs of an
acute worsening of his COPD, which is known as COPD exacerbation. (In (1)
many cases, COPD exacerbation is the result of a relatively mild
respiratory tract infection, but could be due to something more serious,
such as pneumonia).

The physician in the ED ordered a chest x-ray, which did not show any
signs of pneumonia. He admitted Mr. Londborg to the hospital for
treatment of acute COPD exacerbation, resulting from a relatively mild
respiratory tract infection. Before leaving the ED, Mr. Londborg also
underwent routine blood work, which showed an elevation in his
creatinine, a sign that his kidneys were being forced to work harder due
to his infection.

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On the medical floor, the care team treated Mr. Londborg with oral steroids and
inhaled bronchodilators (standard medical therapy for his condition), which resulted

ADDITION
in a gradual improvement in his respiratory symptoms. Nurses also gave him IV
fluids for the issue with his kidneys, which slowly resolved.
Mr. Londborg was steadily improving, so it seemed this visit to the hospital would be
one of his shorter ones.

AL CASE
But on his third morning in the hospital, Mr. Londborg complained to the intern (a
first-year resident) on the care team about acute pain in his left leg. This symptom,
potentially indicating deep venous thrombosis (a blood clot in his leg commonly
known as DVT), prompted the team to order an ultrasound of Mr. Londborg’s lower
(2)
extremities. (A primary concern with DVT is that blood clots in the legs may dislodge
and travel to the lungs, causing a pulmonary embolism, which could be deadly.)

The resident on the care team (who oversees the intern) then checked Mr.
Londborg’s medication orders and was surprised to see that the admitting doctor
had not ordered prophylaxis for DVT (i.e., blood thinners, such as heparin or
enoxaparin). The resident was surprised because patients admitted to the hospital
typically receive this treatment to prevent blood clots from forming while they lie in
their hospital beds. Further, nothing about Mr. Londborg’s medical record suggested
he shouldn’t have received this treatment as an important precautionary measure.

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  The patient did not receive
standard treatment to prevent the
formation of a DVT. What are
DISCUSSION some possible reasons why this
error occurred?

QUESTIONS  Can you suggest system process

improvements that might reduce
the likelihood of similar errors in
the future?

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 Summative:
 In the context of the current social and political climate, how
can organisations be held accountable for the quality of care?
 4000 words
 100% module weighting for grade

ASSESSMEN
Support:
 The assignment is the opportunity to reflect on the learning
from the module, to provide evidence of an understanding of
clinical governance and to critically examine how healthcare

T REMINDER
organisations are held accountable to the public for the quality
of care that they and their staff deliver.
 There may be various approaches and students may choose to
look at alternative aspects but there will need to be a structure,
there will need to be evidence of critical analysis of Clinical
Governance in the UK or in your country and it will need to
meet the Masters level objectives of the module.

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 1. Please go to your module space
on moodle and download the
formative template
2. This is an opportunity to break
down the essay question into
different parts and gain
qualitative feedback feedback

FORMATIVE 3. Please include a relevant

reference list
4. Maximum word count: 1000
words
5. Submission: 31 October,
23.59pm
6. See moodle for all of the details

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