Clinical risk management in practice

GPs need to be aware of any possible treatment risks and take appropriate measures, says Dr John Sandars

Risk is a natural part of all healthcare. There is always the potential that an unwanted or unexpected outcome will occur whenever any action is taken. Clinical risk management is therefore essential for improving patient safety, and all practices are expected to undertake it as part of their clinical governance procedures.

Be proactive
Historically, risk management has tended to be used reactively, in response to an adverse incident, but there is increasing demand for it to be used proactively. Remember the five Ps: perfect planning prevents poor performance.

Be aware of the possible risks associated with a proposed treatment and the balance of benefit versus harm, and consider the range of alternative management strategies. This is essential if high-quality care is to be provided and patient safety is to be maintained. This planning can avoid serious consequences to both the patient and the healthcare professional.

People often think that all risks can be avoided, but this is unrealistic. It is important to remember that risk is constantly present in medical practice.

However, risks can be minimised by planning ahead, and following a four-step risk-management procedure.

Risk identification
The first step is to identify the risk. A common method used for this is critical incident analysis or significant event review. This identifies risks after an event has occurred. It involves reflecting on past events that have caused harm or have been identified as having the potential to cause actual harm.

The importance of near-misses, in which potentially harmful events are considered, is that these events usually identify underlying problems with the provision of healthcare, such as sloppy procedures or insufficient training. Prompt remedial action at this stage can prevent future tragic events.

A more proactive approach is to consider the possible risks before any treatment is given or procedure is performed. For example, before prescribing penicillin it is essential to consider the risk of an allergic reaction but it is also important to ascertain any problems in swallowing the medication or remembering to take the prescribed dose.

Risk analysis
Once a risk has been identified, it should be analysed to determine what action needs to be taken to eliminate or reduce it. The potential likelihood of harm has to be considered.

Difficult decisions often have to be made about a risk that is rare, but potentially very serious, compared with a risk that is very common but has a low probability of causing harm. An example is the risk of a flare-up of asthma when NSAIDs are used.

Risk control
In some circumstances it may be possible to avoid the risk by understanding the causes of it and taking appropriate actions.

It will not always be possible to eliminate risks entirely but risk-control measures can be introduced that reduce the likelihood of an adverse outcome. These include policies, clinical guidelines and patient care pathways.

These are also important for contingency or disaster planning, in which possible worst-case scenarios are considered. An example is the use of protocols when using methotrexate.

Risks can be minimised using various control strategies which have been developed to limit the potential consequences of a given risk without accepting or avoiding it. This is the main approach to clinical risk management and is achieved through training of healthcare workers, patient education, policies and procedures.

In cases where the risk of managing a problem in primary care is too high, then risk transfer may be appropriate. This means moving the at-risk patient to another context, such as secondary care, before treatment.

Evaluation
Finally, the effectiveness of the various approaches used to identify, analyse and treat a risk should come under scrutiny.

It is useful to have a multi-professional approach with the adoption of a ‘blame-free’ culture so that people can honestly give their opinion. 

Dr Sandars is a senior lecturer in Community Based Education in the Medical Education Unit at the University of Leeds, West Yorkshire 

Learning points
How to reduce the risks of treatment in primary care 

  1. Be proactive about identifying and controlling clinical risk. Remember that risk is constantly present in medical practice.
  2. Reflect on past events that have caused harm and on near-misses to identify any underlying problems that could be solved.
  3. Consider the risks of treatment in advance. 
  4. Analyse risks to work out those which can be avoided and those which can be minimised using risk-control strategies.
  5. In cases where the risk of treatment is too high for primary care, transfer the patient to secondary care.
  6. Evaluate risk management strategies regularly. 

Resources

  • Lilley R, Lambden P. Making Sense of Risk Management (2nd edition) Radcliffe Publishing: Abingdon, 2005.
  • Haynes K, Thomas M. Clinical Risk Management in Primary Care. Radcliffe Medical Press: Oxford, 2005.
  • Online postgraduate certificate in Patient Safety and Clinical Risk Management at the University of Leeds.

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