How to approach risk management
| At the end of May members of the
Faculty of Prescribing and Medicines Management (FPMM) held their
annual conference to hear about risk management and patient safety.
Rosalind Grant reports on the meeting, in the light of the fact
that the national reporting and learning system is due to be launched
by the National Patient Safety Agency in November |
Rosalind Grant Head of medicines management, Bath & North East Somerset PCT FPMM Board Member
|
Parallels exist between the airline industry and the NHS acccording to
Andy Shaw, head of corporate safety and security with British Midland.
He described risk management in the airline industry and highlighted
potential parallels to the NHS.
Placing risk management in context, Mr Shaw defined it as “the
process which achieves the most efficient combination of controls necessary
to provide reasonable assurance that business objectives can be achieved
reliably”.
Companies have to balance their efforts and resources in managing risk
ensuring that the legal standards, that is the minimum standard, are
met. Firms like British Midland that aim to deliver above the minimum
standard are likely to add value, minimise losses and protect their business.
Systematic approaches essential
“You cannot control every risk but a structured process embedded
in management can close the gaps,” he said. Mr Shaw defined the
process of risk management as a modern systematic approach of identification,
evaluation
and subsequent control, to reduce the impact on a business.
He illustrated this with the story of the ‘Herald of Free Enterprise’,
the ferry that capsized outside Zeebruggee port with the loss of over
90 lives in 1987. Systematic failures were identified in management,
communication, supervision, allocation of workload, prioritisation, technical
issues, resourcing and procedural compliance.
System failures in NHS
These systems failures have also been identified within the NHS and,
after a series of high profile drug administration errors, they led
to the publication of An Organisation with a Memory (Department of
Health 2000). This introduced all parts of the NHS to risk management
and a move away from blame-centred culture to an open and learning
one.
Introducing the plans for the nationally co-ordinated system to prevent
medication errors Professor David Cousins, Head of Safe Medication Practice,
National Patient Safety Agency said that no matter how knowledgeable
or careful we are, there will always be situations in which errors are
possible or even likely. Professor Cousins highlighted the impact that
medical and medication errors have in the UK:
• Adverse events occur in around 10 per cent of hospital admissions
• Around 850,000 adverse events occur a year
• Adverse events cost approximately £2 billion/year in additional
hospital stays
• Clinical negligence claims paid by the NHS expected to be £600
million this year
• Medication errors account for around a quarter of incidents that threaten
patient safety
What are medication errors?
A medication error is defined as any preventable event that may cause
or lead to inappropriate medication use or patient harm while the medication
is in the control of the health care professional, patient or consumer.
Although this is a US definition it is equally applicable in the UK.
A medication error can arise not just in the usual scenarios of professional
practice associated with prescribing, dispensing, administration and monitoring,
but also in relation to product labelling, packaging and nomenclature of health
care products or to ordering or communication problems in procedures and systems.
The NHS view is that avoidable failures occur, errors that could be prevented
keep recurring, lessons learnt from incidents that occurred in one hospital
do not transfer across the health service and circumstances that predispose
to failure are not well recognised.
To improve safety and foster a culture of openness and reporting, the Government
has set up a national system for reporting and identifying adverse events,
near misses and professional errors in health care. The NPSA aims to involve
patients, the public and health care professionals in its work and to restore
confidence in the NHS. The NPSA will cover all aspects where an error, now
renamed patient safety incident, is identified. The national reporting and
learning system will be web-based and is due to go live in November.
Patient safety managers, one per strategic health authority area and each with
a budget of £100,000, will support local development and patient safety
initiatives.
Other initiatives
To illustrate some of the work underway at the NPSA, Professor Cousins
discussed the action being taken with intravenous potassium chloride,
the drug most frequently implicated in medication errors. The message
to acute trusts is that they do not have to purchase poorly packaged
and labelled products. Purchasing for safety will be key throughout
the health care system, including community pharmacies, and should
involve a risk assessment of all new medicines and packs.
Professor Cousins suggests that drug and therapeutics committees should
have products on the table when making decisions about which one to adopt
so that issues around labelling, packaging, storage, prescribing, preparation
and administration can be discussed as part of the drug selection process.
Thought also needs to be given to training and information requirements
before the product is introduced into practice.
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