Clinical Risk Management Health And Social Care Essay.

Clinical Risk Management Health And Social Care Essay.


The aim of this article to provide the reader with perception to the word ‘professional medical risk management’ and how this is carried out within NHS trusts concentrating especially on the role of Pharmacists in doing this.Clinical Risk Management Health And Social Care Essay.


Defining ‘scientific risk management’ and speaking about its importance

Discussing ways in which trusts implement clinical risk management

Defining exactly what is a medication error and identifying the role of the pharmacist to lessen these

Discussing systems or operations in place in my own base hospital to lessen medication errors

1. 0 Importance of specialized medical risk management

Clinical governance was initially mentioned in British isles Health policy in 1997 as a term used to spell it out the accountability operations for scientific quality of treatment. It improved as a system to address and react to a series of high profile media cases highlighting poor quality patient care as uncovered in the Nottingham IT vincristine catastrophe, Bristol Heart and soul surgery, Shimpan and Alder Hey organ retention.Clinical Risk Management Health And Social Care Essay.

During I997 in Britain, the Section of Health publicized the white newspaper the ‘New NHS; modern, reliable’ which released Clinical governance as a way of accounting for specialized medical quality in healthcare but really came to prominence in 1998 when Scally and Donaldson appraised ‘Clinical governance and the drive for quality improvement in the NHS’ in the Uk Medical Journal. The newspaper highlighted four the different parts of quality as at first identified by the World Health Organisation:


Professional performance (technical quality)

Resource use (efficiency)

Risk management (threat of injury or illness associated with the service provided)

Patient satisfaction with the service provided.

Majority of NHS good care is of an extremely high standard and compared to the high volume of care provided on a regular basis in medical center and community, incidence of serious failures are unusual. 1 However when they do happen, they have devastating consequences for specific patients and people. 1 Greater patient anticipations, knowledge and media exposure of high profile cases have led to the NHS being scrutinized concentrating on its insurance policies of operation, facilities and functioning culture.

It is projected that an average of 850, 000 undesirable events may occur in the NHS clinic sector every year resulting in a 2billion immediate cost in additional hospital days exclusively. 1 Poor specialized medical performance ends up with patient damage and loss of patient’s self-confidence in the NHS services as well as a rise in litigation costs. 4 In 2009/10, 6, 652 claims of clinical negligence and 4, 074 says of non-clinical neglect against NHS systems were received by the NHS Litigation Expert, up from 6, 088 promises of clinical negligence and 3, 743 claims of non-clinical neglect in 2008/09. 4 787 million was paid regarding the clinical negligence says during 2009/10, up from 769 million in 2008/09. 4

Errors are talked about as either ‘real human’ or ‘systematic’ in the Section of Health record ‘An organisation with a storage area’. As an NHS company the focus is systematic, a far more holistic way when dealing with errors. This approach recognises the importance of resilience within organisations and this errors direct result as a number of interacting factors and failures within the system. 1

NHS Quality Improvement Scotland (NHS QIS) scientific governance and risk management benchmarks identify risk management as the:

Systematic identification and treatment of risk

Continuous procedure for minimizing risk to organisations and people alike

Culture, functions and constructions that are aimed towards realising potential opportunities whilst taking care of adverse events

In the past, professional medical risk management was poorly maintained in the NHS. There have been no individuals chosen to control risk management, occurrence reporting in most important care was basically ignored, there was no standard method of incident inspection, and existing systems didn’t facilitate learning across the NHS. 1 Inside the 1990s there was a concerted drive to build up risk management and risk management within NHS organisations. 1 Following on from this there’s been an increased awareness of the reason for medication errors in NHS trusts and how these can be avoided. 1 In 2000, the federal government made a commitment to reduce the pace of serious errors by 40%. The innovations in technology and knowledge in recent ages has resulted in a more intricate healthcare system. 2 This complexness carries risks and evidence shows that things do and will go wrong in the NHS sometimes resulting in patient damage. 2

The NHS quality improvement strategy1 encompasses;

Clear nationwide quality requirements; NICE, NSF

Dependable local delivery; systems of scientific governance in NHS organisations

Strong monitoring mechanisms; a new statutory payment for health improvement, an NHS performance assessment framework, and a national study of NHS patient and user experience.

It is hoped adaptation of these approaches in individual NHS organisations must have a positive impact on the development to identify, prevent and study from system failures at a local level. 1 The intro of medical governance provides NHS organisations with a robust imperative to give attention to tackling adverse health care events1. It’s high time for a fundamental re-thinking of the way that the NHS approaches the troubles of learning from an adverse health care event.Clinical Risk Management Health And Social Care Essay. 1

2. 0 Implementing Risk Management within NHS trusts

The Department of Health publication ‘An organisation with a recollection’ facilitated the patient safety motion in the NHS. 2 It proposed solutions to risk management incidences through the culture of openness, confirming and safety consciousness within NHS organisations. 2 Four Key areas outlined from this record were:2

Unified mechanisms for confirming and analysis when things fail;

A more wide open culture where incidents or service failures can be reported and mentioned;

Systems and monitoring procedures to ensure that where lessons are identified the necessary changes are placed into practice;

A much wider understanding of the value of the systems procedure in preventing, analyzing and learning from patient security incidents.

In reaction to an organisation with a memory, the Government statement Building a safer NHS for patients focuses how to use these recommendations2. It specified a blueprint for a countrywide Incident reporting system and reviewed the role of the Country wide Patient Safety Organization (NPSA). 2 The NPSA was setup by the Division of Health in 2001 with the aim of preventing harm from risky medications. The NPSA produced the National Event reporting and Learning system (NRLS) to set priorities, develop and disseminate actionable learning following reviews of patient security incidents.Clinical Risk Management Health And Social Care Essay.

Following this guidance all NHS trusts should have a risk management strategy set up. This consists of systems for the recognition of all hazards which may bargain delivery of patient health care. To assist with this trusts are obliged to deliver patient services in compliance with statutory rules according to nationwide and local requirements highlighting the particular level and quality of services required. The implementation of risk management policies within NHS trusts will be overseen by Clinical Governance managers and Risk managers4. Trust Risk management strategies will need to be regularly examined and audited; individual trusts will have Risk Professionals within each section to oversee this4. The Trust Mother board will ensure that risk management, quality and security receive priority and the required resources within budgets.Clinical Risk Management Health And Social Care Essay.

Pharmacy departments will have a medicines management team comprising of an risk management pharmacist to execute risk management at an area level. The Risk management pharmacist will ensure staff know about risk management issues both locally and nationally and will update personnel on actions to be studied to minimise risk thereby promoting conformity with exterior risk management requirements. The risk management pharmacist will also have to ensure local risk management insurance policies are kept current.

In order to deliver the chance management agenda, specific trusts must meet the requirements of the NHS Litigation Power Risk Management expectations and the Health care Quality Commission rate standard’s (CQC) from medical and Social Function 2008. From Apr 2010, NHS providers should register with the CQC and offer proof of adherence to specifications establish by the CQC5.Clinical Risk Management Health And Social Care Essay.

2. 1 Country wide Patient safety firm and National Reporting Learning System

In 2001, following publication of the Section of Health record and ‘Company with a Ram’1 the National Patient safety organization (NPSA) was setup. The launch of the NPSA has for the first time provided a organized focus on medication basic safety6. The purpose of the NPSA is to lead and donate to better, safe patient care and attention by informing, assisting and influencing organisations and folks working in medical sector with one primary goal – ‘to improve patient safeness by reducing the risk of damage through problem’7. The NPSA’s effort was to recognize patterns and trends in avoidable undesirable events so the NHS could execute changes to prevent these happenings from reoccurring.

The NPSA will 2, 8:

Collect and analyze information an adverse events in the NHS

Assimilate other safety-related information from a number of existing reporting systems

Learn lessons and ensure they are fed back into practice

Where risks are identified, produce solutions to prevent injury, specify national goal and build mechanisms to track progress

The NPSA then proceeded to go onto produce the National Incident Reporting and Learning system (NRLS) which is designed to recognize and reduce the risks to patients receiving NHS good care and leads on countrywide initiatives to boost patient safety. You can find NHSLA risk management requirements for each type of NHS health care organisation. The criteria will address clinical and non-clinical health and safety hazards. 4 Individual trusts will be evaluated regularly and assessed against benchmarks to ensure a risk management strategy has been devised, it is set up throughout the trust, it is workable. 4 This can minimise litigation costs resulting in more funds open to trusts to improve patient care and attention; providing an incentive for better medical and non-clinical risk management.Clinical Risk Management Health And Social Care Essay.

The NRLS gathers confidential data on medication mistakes from all NHS trusts in Britain and Wales and boosts patient protection by allowing the NHS to study from patient safety incidents8. This builds on incident confirming systems which were previously used on an adhoc basis in specific trusts. The NRLS reporting system has been designed to be compatible with local risk management systems that are used in majority of NHS organisations. 2 NRLS reports are analyzed by clinicians and protection experts8 and key themes and trends adding to patient safety happenings are determined. 2 Steps are then taken to minimize these dangers through the development and prioritisation of national solutions.Clinical Risk Management Health And Social Care Essay.

‘Trusts reporting happenings regularly suggest a better organisational culture of safety’. 8 Encouraging staff to record clinical incidents impacting on patient safe practices can help put into practice risk management strategies within NHS trusts. The greater incident reports posted a lot more data available to speedily identify and act upon patient safe practices occurrences. The NRLS suggests trusts should be submitting incident reports once a month. 8 In pharmacy these will largely involve incidents relating to medication mistakes.

The development and campaign of the NHS ‘reasonable blame’ culture prompted error confirming reassuring staff the main causes of problems will be looked into. However, insufficient awareness and fear of disciplinary action stay as a few of the main barriers to incident reporting. 8 To triumph over this staff need to be effectively trained on when and the way to report clinical occurrences. At my bottom medical center, incident-reporting training is included in the trust induction and at an area pharmacy level as an in-house induction.

Each trust occurrence is graded relating to standardised NPSA rating systems; 1 being minimal with no injury to patient ranging to catastrophic level 5 i. e. patient loss of life. Following the conclusion of a web based incident form, the chance lead for that one area will get a duplicate of the report. These reviews will be analysed and correctly graded and any serious situations will be reported to the Trust Table via the risk management committee.

A record by the NPSA mentioned the mostly reported remedies related incidents to be:8

Wrong dose, durability and rate of recurrence of medicines

Wrong medicine

Delayed and omitted doses

Medicine related happenings will be reported to the Risk Management pharmacist who will provide reviews to the pharmacy team. All category 4 and 5 occurrences have a full root-cause examination performed and are published to the NRLS. These reviews are then analysed by the NPSA, if necessary swift response notifications are produced. 1, 8 Rapid response alerts become a crucial means to focus the work of trust professional medical risk professionals into proven high risk areas. 8 Delayed and omitted dosages of medication resulted in the production of a recent quick response alert. This alert was sent to trusts by the NPSA via the NHS’s Central Alerting system. 8 On receipt of the alert, trusts were expected to respond and act upon requests comprised within it within the given deadline provided. Each alert consists of instructions for regular audits in order to examine the action used.Clinical Risk Management Health And Social Care Essay.

3. 0 Medication Errors

Most medication are not without adverse effects and most aspect effects and negative incidents are predictable, thus exposure to these adverse incidents can be minimised or averted through careful prescribing and usage. Nevertheless some undesireable effects are unpredictable and for that reason unavoidable. 6 However medication problems occurring therefore of blunders or lapses when medications are recommended dispensed or used are avoidable. These can be related to apply, techniques, products or systems. 6

Medication mistakes as defined by the NPSA are

‘any preventable event(s) that could cause or lead to incorrect medication use or patient harm while the medication is in the control of medical attention professional, patient or consumer. Such events may be related to professional practice, healthcare products, strategies and systems, including prescribing; order communication; product labeling, presentation and nomenclature; compounding; dispensing; syndication; supervision; education; monitoring; and use. ‘ 10

Numerous studies have been conducted to research the occurrence and effects of medication-related injury. A 2008 study conducted in an emergency section in Scotland found 2. 7% of admissions were related to unfavorable medication reactions. 11 In 56. 7% of circumstances the adverse medication effect was the recorded reason for entrance but only 13. 3% were considered to be inevitable. 11 Another study carried out by Charles Vincent examined more than 1000 details and found that 10. 8% of patients experienced a detrimental event and this half of these were preventable. 12 It was found that a third of these undesirable events resulted in either serious outcomes or death. 12 Medication mistakes also occur in other health care systems, and is also estimated harmful errors take place in 1. 8% of clinic admissions in the United States, leading to about 7, 000 fatalities every year. 6 Similarly, an Australian research showed that 0. 8% of inpatients suffered a dangerous medication problem. 6

3. 1 Why do medication errors occur?

To have the ability to reduce the risk of medication errors, the cause of medication errors need to be understood. 6 Previously medication errors were thought to be the sole responsibility of the individuals considered to be the cause of the mistake. However, now a more holistic methodology is taken and it is acknowledged errors appear when both human and system factors interact in a chain of happenings – often sophisticated- leading to an undesirable end result. 6 Not only the individual at fault but latent conditions within an company and triggering factors in clinical practice also needs to be looked at as important causes of mistake as well. 6 As Lucian Leape, the Medical doctor and Teacher at Harvan university of Consumer Health said:Clinical Risk Management Health And Social Care Essay.

‘Human beings make mistakes because the systems, tasks and processes they work in are inadequately designed. ‘ 6

Human factors derive from the individual and may occur credited to lack of training and education and lapses in amount. System errors result from the working of the company and the lack of policies and types of procedures in location to reduce medical risk. Recent experience shows using situations those safeguards have not been adequate and still have failed to prevent serious error and injury to the patient. 6

Active failures and latent conditions cause slots in the defence system to start. 6

The energetic failures occur as a result of unsafe practices of people working with something, for example the prescriber failing to double check a prescription, or the pharmacist failing woefully to identify an incorrect dose on the prescription. 6 Latent conditions occur because of the composition of the organisation and its own resources, management and operations in place. 6 These either only or in mixture with an active failure, can lead to error. For example having less a computerised prescribing system with inbuilt systems to point out an erroneous prescription or having less an efficient communication system between most important and secondary treatment. 6

3. 2 The role of the pharmacist in managing medication errors

Pharmacists as experts in medications have an invaluable role in lowering medication errors. As a profession and specialists in the careful use of medicines we have been best located to minimise the risks associated with medication use. 12

The federal ‘security of doses’ report advised seven action factors to improve medication safety. These are:13

Increase confirming and learning from medication event.

Implementation and audit of NPSA medication alerts assistance.

Improve personnel training and competence.

Minimising dose problems.

Ensure drugs not omitted.

Ensure appropriate medicine correctly tagged gets to the patient.

Document patient allergy position.

The three regions of concentrate in medication error reduction for Pharmacists to discover preventing are:12

Risk in the medication itself.

Risk in the make, storage, and circulation of drugs.

Risk in use of medicines.

Pharmacy departments all together are similar to high quality manufacturing items and test each stage in the production, storage and syndication of drugs. 12 Pharmacists are involved in almost all periods of the medication circuit from clinically examining of the prescription to the accuracy checking and final release of the medication dispensed. Inside the pharmacy culture there is the expectation for errors to occur and therefore systems have been developed and devote location to minimise these. 12 Types of pharmacy services to reduce medication related errors in hospitals are:12

Checking of prescriptions and offering of drugs.Clinical Risk Management Health And Social Care Essay.

Ward drug graphs.

Use of the knowledge and pharmacokinetics to examine toxic and sub-therapeutic doses.

Quality control and assurance measures.

3. 2. 1 Ward centered Pharmacy services

Pharmacy services at ward level were first suggested as a health plan in 1970 and also have proven to find preventing prescribing mistakes. 12 The role of the pharmacist is ever before changing and pharmacists are becoming recognised as an integral part of the multi-disciplinary team. The pharmacists role has shifted from the original ‘source role’ to a far more ‘specialized medical role’ allowing pharmacists to utilize their expert understanding surrounding medication use to reduce medication mistakes at ward level. Pharmacists are a lot more effective at ward level and as such are actually the first interface of demand advice on medication by patients and other healthcare experts. The pharmacist’s role also extends to drugs management and formulary development, drugs information and involvement in various dispensing phases. Throughout these different functions the pharmacist’s remain productive to advertise safer practice and reduced amount of medication problems.

3. 2. 2 Medications Reconciliation

Medicines reconciliation is a process designed to ensure that medication an individual happens to be taking is effectively documented on entrance with each transfer of good care. It includes:




The National Institute for Health and Clinical Excellence (NICE) in collaboration with the NPSA released direction to ensure appropriate processes are in place to assure any medication patients are taking previous to admission is properly documented on admission to hospital. 8 The NPSA reported the amount of happenings of medication problems involving entrance and discharge as 7070 with 2 fatalities and 30 that brought on severe injury (numbers from November 2003 and March 2007). 8 An accurate medication history is necessary to assist safe prescribing.Clinical Risk Management Health And Social Care Essay.

To improve drugs reconciliation at clinic admission NICE/NPSA has suggested that:8

pharmacists are involved in medicines reconciliation as quickly as possible after admission

the tasks of pharmacists and other staff in the medications reconciliation process are clearly defined; these tasks may differ between specialized medical areas

strategies are included to obtain information about medications for individuals with communication troubles.

At my bottom hospital, drugs reconciliation entails doctors, nurses, pharmacists and pharmacy technicians. Systems and regulations are in location to deliver medicines reconciliation in different areas of attention and to ensure all personnel mixed up in drugs reconciliation process are certified and effectively trained.

3. 2. 3 Education and Training

At my basic hospital information regarding professional medical risk management is widely accessible to all staff through a variety of sources; alongside co-operate medical mandatory training sessions and in-house local workout sessions, a multitude of information is on the local trust intranet. Included in these are a governance newsletter entitled ‘Lessons Learned’ detailing unfavorable events which have occurred and steps taken up to prevent reoccurrence of such occasions, risk management guides available on-line and the NPSA patient safeness literature. At a local pharmacy level, the regular monthly medicines management bulletin includes medication safety updates and is distributed to all pharmacy staff.

As well as these procedures education and training to other healthcare pros and patients on medication is paramount. Pharmacists are the professionals best placed to get this done. The Central Manchester Groundwork Trust took part in a prescribing error audit known as the EQUIP research. This exhibited pharmacists as experts in medications held very helpful knowledge and through organised education programs can lessen medication mistakes. 14 The root cause of prescribing mistakes amongst newly certified medical personnel was simply scheduled to lack of knowledge regarding drugs. 14 Results confirmed the necessity for pharmacists at ward founded level and preventing potentially serious medication errors through their presence on the ward. 14 Pharmacists on wards provided medical personnel immediate access to advice regarding dosing, interactions and restorative monitoring of drugs. 14 Pharmacists are also more likely to complete incident reports involving medications and should encourage other staff to do the same. Ensuring staff are aware the only path to enhance the systems in place is to learn whatever we are doing wrong.

Pharmacists are also involved with developing and delivering teaching trainings for various groups of staff. Cases included within my base medical center are VTE prophylaxis, IV drug calculations and monitoring for unfractionated heparin. All Pharmacists should deliver and attend teaching sessions early on in their career. As well as educating medical staff, pharmacists counselling of patients in outpatients with release will also aid decrease in medication problems.

As well as delivering information and teaching packages, pharmacists must ensure information provided is sufficient, easily accessible and up to date. Treatments information pharmacists will review how best to provide information for safe prescribing and drug administration. 6 The formulation and dissemination of medication policies and professional medical guidelines by pharmacists plays a part in associated risk management. Pharmacists also advice clinicians on risk issues arising from quality assurance accounts e. g. NPSA, nationwide and local professional medical audit. 4

3. 3 Decrease in medication errors

Medication errors arise due to lots of failures. Pharmacists clinically researching a prescription can find preventing prescribing mistakes, but prescribing is merely one aspect of the medication pattern. 7 Failures in the operations of reviewing, dispensing, administering and monitoring of drugs also arise. 7 To overcome these sufficient systems and checks to avoid medication errors have to be in place. Examples of such systems include:13

Effective communication

Education of all health care professionals

Integrated electronic good care records

Systems and guidelines set up for buying, dispensing, administering and moving in medicines

Providing a day drugs information services and support to medical staff

Increase specialists staff, more training for junior personnel from an undergraduate level and upgraded discharge procedures

Development of it services and standardised digital occurrence reporting systems

3. 3. 1 Information Technology

The advancements of scientific systems have helped in the running of medicine founded services you need to include robotic dispensing systems and electronic digital prescribing. Similar packagings of medications by the same make lead to frequent dispensing problems. The implementation of automated dispensing robot in my trust has significantly reduced problem rates through the incorrect selection of medication. In addition, it minimises administration mistakes through the production of standard alert brands such as Methotrexate weekly dosing warnings, and reminders to attach ‘penicillin containing’ stickers to relevant antibiotics. However, the system is not fool facts and therefore errors still occur mainly due to over reliance triggering staff to be deskilled. Close to miss audits to recognize potential errors are conducted regularly within my trust to highlight regions of matter and systems put in location to prevent these mistakes reoccurring.

Implementation of digital prescribing systems (medisec) for release and electronic dose calculator on our neonatal device has also proven to reduce medication errors. Medication errors due to illegible handwriting no more occur minimising threat of dispensing mistakes. The availability of drug name, medication dosage, formulation and dosing agenda also have reduced the chance of medication problems. 7

3. 3. 2 Medication safeness at discharge

Poor communication between different healthcare professionals can lead to medication errors at discharge. Medicines reconciliation on entrance has proven to be useful in linking patient’s health care at primary care and secondary care and attention. However, more concentrate needs to be placed on guaranteeing community pharmacists and Gps device are aware of changes to medication at the idea of discharge. Improved communication will prevent GPs from prescribing drugs that are no more mentioned, contra-indicated or even duplicate drugs. 7 The implementation of the digital discharge system medisec and the automatic electronic backup of the discharge summary describing information regarding medication changes has proven to be a good tool in bettering communication to Gps navigation, and maintaining the hyperlink between primary care and secondary health care. In addition to this, patients receiving a copy with their discharge conclusion and being counseled on their medication at the point of discharge will contribute to reducing medication problems.Clinical Risk Management Health And Social Care Essay.

4. 0 Conclusion

The need to manage risks is particularly important in the NHS because of:

Finite learning resource – the NHS has a restricted amount of money and personnel to give a service

Complexity – the service we provide is extremely complex because of both size and dynamics of the task

Expectation – we strive to meet the anticipations of an increasingly aware public

Clinical Risk Management is an essential part of clinical governance and thus everyone’s business. Managers in every areas are accountable for ensuring that risks in the area are identified, supervised and controlled based on the Trust’s Risk Management Strategy. This can contribute to improved upon delivery of services by providing a structured method of decision-making. . All staff employed in the NHS have a responsibility to be aware of and put into practice risk management within their individual job tasks. The introduction of technology, systems and functions and education of most staff would be the key to implement professional medical risk management at local and nationwide levels in specific trusts.Clinical Risk Management Health And Social Care Essay.