Identifying Systems Risk as a key to Adverse Event Prevention
Deanne Emmerson
This paper was presented in June 2001, at the annual conference of Australian Association for Quality in Healthcare, around the theme of Quality in the Health Industry, where Deanne Emmerson of Quality Award Partners Pty Ltd, was a keynote speaker.
Risk according to Tweeddale is "the probability or likelihood of an undesirable event or outcome". Therefore risk management can be seen as how we go about dealing with such probabilities and likelihood. In other words how we manage the possibility of things turning out as less than satisfactory.
The Scope of Risk Management
Many perceive risk management as an OH&S issue or adverse event/circumstance analysis and control. This is only a small part of the big picture. Risk Management includes many facets. For example:- assessment; analysis; quantification; evaluation; planning and implementation of controls; communication and evaluation of effectiveness of controls. Viner (1994). Risk management also affects all facets of our organisations including:- patients/clients; finance; IT, contracts; purchasing; and all operational areas across all disciplines. In fact, risk and therefore risk management applies to everything we do within a health facility. For the purposes of this paper, we will look at the impact of system\'s risk on adverse events.
Unidentified and Uncontolled Risk
Tackling adverse events is absolutely necessary so that preventive action can be instituted to prevent or minimize recurrence. The issue however is that adverse events are most often the consequence of unidentified and uncontrolled risk. Quality Award Partners® have found that in many instances, such risks are found to be within the operational systems of the health service. Others also confirm our experience as identified in the following papers.
System Error
A report in February 2000 called, Reducing Medical Errors and Improving Patient Safety, was commissioned by The National Coalition on Health Care and The Institute for Healthcare Improvement (US). A paper in the report written by Lucian L. Leape, M.D. brings to light the absolute importance and impact that systems have on adverse events. "The vital first task is to recognise that as in other complex fields of science technology, engineering and human endeavor, errors in medicine are caused by failures in the systems and organisations that human beings build" This clearly supports the necessity to identify those 'system' deficiencies or discrepancies that result in risk exposure and often system failures that in turn lead to errors.
Leape continues on to say that "We have strict rules governing working hours, procedures, equipment and maintenance for our airlines and railroads. But we have few such rules in health care." Leape concurs here with the view that other industries whose services pose high risks to consumers have very tight systems with strict guidelines that they clearly need to comply with to ensure consumer safety.
Leape also identifies that it is the organisation and its systems that are responsible for errors made by staff and that managers are responsible for those systems. Reference is also made to "the need to shift their focus from individuals to organisations, requiring both a thorough investigation of the underlying systems failures and a plan that addresses those failures." Health Services need to have a structured methodology for identifying and investigating underlying system failures so that they can be addressed thus preventing adverse events.
In the same publication a paper written by Christine Paul of Dana-Farber Cancer Institute Boston, Massachusetts, called Back From the Brink Making Chemotherapy Safer. refers to a fatal medication error stating that "…..behind the human error that caused the death were a host of 'system errors'." Once again, this illustrates the need to identify system risks as a preventative approach to managing adverse outcomes with the aim of preventing their occurrence.
Prevention Rather Than Blame
The publication also included a paper by Lani Luciano called A Government Health System Leads the Way. Luciano discusses the method used to reduce the incidence of medical errors and the implementation of a close call initiative. "Close Calls show us weaknesses in the system just as harmful events do, but at a much lower cost in human misery and wasted resources." Identifying system risks is akin to a close call in that it too identifies a potential situation where a harmful event can occur. Thus a preventative approach to identification of such risks can, like a close call, be the flag for preventive action to be implemented.
We need to question why we concentrate our efforts in trying to locate the source from which adverse events arise after an event has happened. It is clear from the above literature that research into adverse events has identified "system errors" as a major contributing factor. Hence it is imperative that first line risk management strategy be focused at identifying system level risks with the aim of preventing adverse events. When working with health services, our experience has shown that commencing and scheduling regular risk assessments of the operational systems within the health service helps to identify system risks that can lead, if uncontrolled, to adverse events.
References
The National Coalition on Health Care and The Institute for Healthcare Improvement (US). 2000, Reducing Medical Errors and Improving Patient Safety.
Tweeddale M. 1994, Risk Assessment Models; Paper presented at Futuresafe Conference Sydney.
Viner D. 1994, Accident Analysis and Risk Control. VHMS Pty. Ltd., Australia.
Find out more about Operational Risk Assessment:
Contact Deanne Emmerson Tel. 03 9844 2111. Email: demmerson@qap.com.au Click here.