Hospital Pharmacist
2007;14:272-274
September 2007

Risk registers — benefits for medicines management

By Steven Campbell, BA (hons)

This article describes a pharmacy technician’s involvement in a project to improve medicines management through development and maintenance of a risk register

Focus on technicians series

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NHS trusts are required to meet an increasing number of targets and standards with a greater emphasis being placed on clinical governance.

The governance agenda, linked to developments such as the Department of Health’s former Controls Assurance Assessment, the Healthcare Commission’s Acute Hospitals Portfolio and the NHS Litigation Authority Risk Management Standards, as well as internal auditing, challenges NHS trusts more and more to meet set standards. More importantly, they must assure themselves and their patients that services are of high quality, safe and continually being improved.

Impetus for change

In 2000/1, Northumbria Healthcare NHS Trust was rated as performing poorly against the standards of the Acute Hospitals Portfolio. This coincided with a disappointing performance in the Controls Assurance Assessment and, later, the medicines management framework.

Around this time the trust introduced risk registers to their clinical governance arrangements, following the national direction of the Risk Pooling Scheme for Trusts (RPST), to help ensure that areas of poor performance were identified and improved on.

Risk registers are now used throughout the trust with each area rating their risks on a scale of likelihood against consequence. The risk register allows the trust to identify the higher risks encountered by individual wards and departments. As the risk is managed or diminishes, the rating naturally reduces.

The possible consequences of unmanaged risks are more easily identified, allowing more balanced decisions to be made quickly. This is true at ward or department level or at trust management level.

Previous arrangements

Before the national introduction of a risk register style of governance monitoring, the trust relied on clinical governance development plans which were mainly drawn up from Commission for Health Improvement targets. Although action plans were used to support these development plans, they often covered a wide variety of risks throughout the trust and were inconsistent in some cases.

Interpretation of individual risks at ward or department level was often difficult, because of the wide-ranging nature of the action plans, and assigning ownership of risks was challenging.

Managing the register

I began my employment in the trust early in 2004 as medicines management quality and performance lead. One of the main aspects of the role was to manage, develop and update the trust’s medicines management risk register. This required monitoring of performance (eg, by audit, structured assessment) and working with colleagues throughout the trust to recommend actions that would deliver trust-wide compliance with national and local medicines management policies.

I reported progress to a variety of committees and individuals within the trust, including the medicines management committee, pharmacy operational board and trust-wide governance committee.

In 2006 my role changed to pharmacy technical services manager, following an internal pharmacy management reorganisation. I am still heavily involved in risk management and the risk register, but now manage the pharmacy technician specialist for quality and performance, whose role it is to devise and undertake the audits and structured assessments required to maintain the risk register.

Benefits

When the RPST introduced a national modified process for risk management via risk registers, problems with assigning ownership of risk in the trust began to reduce and staff understanding of risks at ward and department level began to increase.

Introduction of the registers has improved the trust’s medicines management risk performance. In May this year 18 risks were recorded by the medicines management risk register, compared with the 95 risks listed in the trust’s strategy for medicines management which was approved in February 2004.

Changes to medicines management processes in the trust, which are recorded and monitored via the risk register, have also led to a reduction in both clinical and financial risk. In 2006 the trust was rated “excellent” in the medicines management category of the Acute Hospitals Portfolio review.

Every ward, department, speciality and now business unit (introduced following the organisation achieving foundation trust status) maintains their own risk register, focusing activities on achieving better governance results. The registers allow wards and departments to focus their development and improvement work on areas of risk from within their own services. This was, perhaps, missing from the previous governance arrangements.

The register provides assurance of medicines-related compliance against national and local policy and legislative requirements and is a substantial aid in pharmacy business planning. The database style of the register allows for easy recording of required actions, timescales, lead individuals and easy monitoring of progress.

One of the main benefits of the risk register, and the approach of our trust to clinical governance in general, is that medicines management and the risks associated with it are becoming increasingly embedded in trust business. The register has played a vital role in communicating the risks associated with medicines to trust managers and staff — from regular reporting at the trust governance committee to the development and introduction of an annual ward-based medicines management risk assessment and interactive learning tools.

Challenges

Engagement The term medicines management is one which can lead to misinterpretation; the expectation being that “pharmacy looks after it”. A major challenge remains to increase staff understanding of the responsibility of non-pharmacy staff in medicines management, and to improve the level of ownership of risks by others.

Pharmacy has made some progress in ensuring that the registers of bed-holding directorates contain the relevant risks attributed to medicines management, thus embedding the risks throughout the business of the trust. An obvious consequence of failing to achieve this would include, at best, a delay in implementation of actions to manage identified risks and, at worst, a failure to identify and deliver necessary change.

Objectivity Risk rating involves a degree of subjectivity. In addition to an individual’s rating of a particular risk, ratings increase or decrease depending on the management of the risk, competing priorities and available resources.

The challenge is to make each assessment as objective as possible and to present this effectively to relevant trust committees, in the knowledge that other departments will also be competing for resources.

Future work

Risk registers are an important risk management tool. They provide assurance to the pharmacy department, the trust and the service users. Monitoring of a risk can easily be maintained once the risk has been identified and added to the register. The tool is simple to use, allowing those less familiar with an issue to interpret the risk better and the actions required to managing it.

At Northumbria Healthcare NHS Foundation Trust we are using the risk register approach to manage the actions required in the five most recent National Patient Safety Agency alerts. Risk ratings, lead officers and deadlines have been assigned to each action to support monitoring and compliance, as well as supporting the improvement work we will be introducing.

Future work will centre not only on maintenance of the register as a performance management and assurance tool, but on using the register to communicate medicines management issues to the wider audience. There is also a need for colleagues throughout the trust to bring any risks associated with medicines management to the attention of the pharmacy department.

This will support a more holistic risk register for medicines management, rather than it being perceived to be “owned” by the pharmacy department.

Acknowledgements David Campbell, clinical director for medicines management and chief pharmacist at Northumbria Healthcare NHS Foundation Trust.