Updated on 30.10.2016.
Evidence Based unbiased information
Clinical Risk Management
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Clinical Risk Management (CRM) has become an integral part of clinical practice. It has been proven that CRM improves the standard of patient care and reduces malpractice. CRM is not merely defensive medicine as it has often been criticised in the past. A thorough understanding of CRM is an essential requirement for all “Good Doctors”. This article discusses the different aspects of CRM comprehensively.
Clinical Risk Management
– themedideas Facts & Figures
What is Clinical Risk Management?
The culture, processes and structures that are directed towards realizing potential opportunities whilst managing adverse effects.
The joint Australia/New Zealand Standard
Clinical Risk Management identifies procedures that may carry actual or legal hazards and minimises them through formal safeguards and protocols.
Could Clinical Risk Management
lead to practising defensive medicine?
1. Initially it was thought to be a means of controlling litigation, but became a need to consider strategies to reduce harm.
2. The narrow view of CRM is negative and defensive, aimed primarily to protect hospitals from claims without any regard to the reasons of claims or to patient well-being.
3. On the positive side, CRM is fundamentally an approach to improving patient care with emphasis on patients who are actually harmed or disturbed by their treatment. It sits well with the clinicians’ exhortation, primum non nocere (firstly, do no harm).
4. Complaints and litigation are part of this procedure.
5. CRM is now a part of Clinical Governance.
Why Clinical Risk Management
is a part of Clinical Governance?
1. Medicolegal claims are a major problem in the National Health Service (NHS) in the UK and all helath services around the world.
2. The costs in the NHS had increased from £53 million in 1990/1991 to £125 million in 1994. Subsequently, the costs increased to around £150 million per year, which constituted 0.5% of the NHS budget.
3. The costs (in percentage terms of the NHS budget) looks negligible, but studies have shown that litigation underestimates the incidence of adverse events.
4. The Harvard Study in 1989 demonstrated that the number of adverse events was seven times that of claims and 14 times that of paid claims.
5. In 1975-1978 the Californian Study showed that only 1 in 10 (10%) patients with an injury due to error filed for malpractice, of which 40% were compensated. This means 1 in 25 (4%) injuries due to probable negligence resulted in compensation.
6. USA has been a prime mover in CRM, because the malpractice costs to healthcare were over $1 billion in 1985 and it has been rising. Adverse events happened to 370 per 10,000 admissions (4%). Of these 4%, 14% died (0.56% of all admissions), 7% suffered permanent disability (0.28% of all admissions) and 70% suffered temporary disability (2.8% of all admissions). If this statistics is transferred to England, for an annual admissions of 8,000,000 this implies 320,000 adverse events resulting in 40,000 deaths and 20,000 permanent disabilities per year. In an average District General Hospital in England with 50,000 admissions per year, this implies 1850 adverse events, resulting in 75 deaths and 37 permanent disability per year.
7. The NHS executive launched a risk management campaign to combat increasing litigation and claims from crippling the National Health Service.
8. Obstetrics and Gynaecology is a high risk speciality and accounted for the second largest (25%) settlement by the Medical Defence Union between August and October 1994. The usual obstetric causes of negligence were retained swabs or instruments (29%), operative injuries (18.3%), perinatal death (17.2%), brain damaged baby (9.7%), antenatal problems (5.4%), perineal damage (4.3%) and others (16.1%). Common problems in gynaecology were failure to obtain informed consent, failure to inform the patient of potential risks and consequences of operations, delayed diagnosis of ectopic pregnancy, operative injuries, retained swabs and instruments, lack of supervision during operative procedures, perforation of the uterus etc.
9. CRM has been shown to improve the standard of patient care and reduce malpractice.
Could Clinical Risk Management eliminate litigation?
It cannot eliminate litigation completely, but it could certainly reduce its number by rectifying human factors responsible for adverse clinical events.
What human factors are responsible
for clinical adverse events?
These are of two types: I. Errors and II. Violation
I. Errors may be subdivided into:
a) Slips, Lapses, Trips or Fumbles, which are failures or deviations that occur at the level of the execution of the action.
* Slips and lapses are unintended actions despite an adequate plan.
* Slips occur due to attention failures and lapses are memory failures.
b) Mistakes are rule based or knowledge based.
* Rule based mistakes may occur due to a bad rule or non-application of a good rule.
* Knowledge based mistakes may occur due to bias or mindset resulting in planning or problem solving failures.
* Mistakes are failures of intention, when the action may go entirely as planned but the plan is inadequate to achieve the outcome.
II. Violation may occur due to routine corner cutting, personal ‘kicks’ or necessity when it is the only available option.
What are the fundamental principles of
Clinical Risk Management?
* The fundamental principles of CRM include Risk Assessment, an adequate plan and its implementation to avoid the occurrence of adverse events and provision of complaint procedures in case of adverse events.
Risk assessment consists of four steps:
i> Risk Identification 1
ii> Risk Analysis and Evaluation 2
iii> Risk Treatment / Prevention 3
iv> Risk Control, learning and sharing 4
1. The starting point is to identify what could go wrong (Risk Identification).
2. Then to analyse how often it is likely to occur and what would be the likely impact (Risk Analysis and Evaluation)
3. Then to check what could be done to minimise the chance of it happening or to mitigate the damage when it has gone wrong (Risk Treatment / Prevention)?
4. The last step is to learn from the experience, share it with others and plan how to eliminate it (Risk Control, learning and sharing)
* The same steps are followed to find the causative factors, the severity of the effect, the cost and finally how to avoid the adverse event.
* Incident Reporting and Root Cause Analysis are two important tools in CRM.
The RADICAL framework
for management of risk in health care
1. Raise Awareness
2. Design for safety
3. Involve users
4. Collect and Analyse safety data
5. Learn from patient safety incidents
Each clinical area should have a risk register. Risks identified through the processes described above should be recorded in the register, showing risk evaluation, controls and residual risk.
How could malpractice be reduced?
The important aspects of clinical practice that could reduce malpractice include:
* Conscientious practice
* Good communication
* Careful record keeping (documentation)
* Taking informed consent
* Proper delegation
* Clinical Risk Management
1. Doherty R, James CE. Malpractice in obstetrics and gynaecology. In: Bonnar J, ed. Recent Advances in Obstetrics and Gynaecology No 18. Edinburgh: Churchill Livingstone; 1994: 91-106.
2. Irvine LM. Practical risk management advice on the labour ward. In: Studd J, ed. Progress in Obstetrics and Gynaecology Vol 12. Edinburgh: Churchill Livingstone, 1996: 59-65.
3. McILwain JC. Clinical Risk Management. Clinical Risk Management Course, Whiston Hospital, Prescot, 19 March 1999.
4. IMPROVING PATIENT SAFETY: RISK MANAGEMENT FOR MATERNITY AND GYNAECOLOGY. Clinical Governance Advice No. 2, September 2009; London:RCOG.
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© Dr Sudipta Paul, themedideas.com, 2013