Clinical Risk Management

Clinical risk management can be defined as actively identifying circumstances and opportunities that put patients at risk of harm and putting in place quality and safety systems and processes to control those risks.

Clinical risk management includes identifying and understanding not only actual adverse events but also things like ‘near misses’ and mistakes, medico-legal risks, and failure of clinical equipment and/or communication process.

The Western Australian Department of Health indicates that clinical risk management is about minimising risks and harm to patients through the following steps:

• identifying what can and does go wrong during care
• understanding the factors that influence this
• learning lessons from adverse events and poor outcomes
• ensuring action is taken to prevent a recurrence, and
• putting systems in place to reduce risks.

Clinical risk management focuses on understanding the probability of harm to a patient that potentially negatively affects the quality of their care.

It is important to use systems to recognise and analyse near misses and adverse events, you can identify, implement, and test solutions to prevent them from happening again. If your practice doesn’t make improvements after identifying an incident that resulted in a near-miss, patients may be exposed to avoidable future adverse events and the practice team may increase their risk of medico-legal action.

This is where clinical risk management and continuous quality improvements come into play.

What do your AGPAL Surveyors say?

What does clinical risk management look like in your practice? It may well be of such second nature to you that you don’t even consider it to be part of a risk management process.

It can be anything from the day-to-day activities you and your team do to deliver care, actions that are taken to identify and reduce risk of harm to your patients, or continuous quality improvements made within your practice.

“The practice needs to have a system, and it can be simple, for monitoring and identifying and reporting a near miss or adverse event. Risk should be a standing discussion item at all practice meetings.” – AGPAL GP Surveyor, Dr Scott Phipps

“Staff should show they know how to report a near miss or adverse event from the moment they are inducted into the practice. The practice should consider who reviews the near miss/adverse event reports and provides direction to change processes if there has been an issue.” he continued.

Mark Brommeyer, Senior Lecturer in Healthcare Management at Flinders University notes that “continuous quality improvement within practices is important as healthcare and related needs are ever-changing, and therefore so should your practice in how it operates and provides care.”

“Quality improvement helps to identify opportunities to make changes to improve patient safety and care and can be achieved in a number of ways. These include regular review of practice structure, systems and operations and the services provided” he continued.

“Quality improvement changes should be based on your own practice and the data you collect, be it patient feedback, team or staff feedback and suggestions and audits,” Mark finished.

Where to look for near misses

While your practice may never have experienced an actual adverse event (an incident), it most certainly will have been exposed to near misses. A near miss can take many forms, with the same area or topic generating many pathways for clinical risks.

Near miss examples include:

• A GP missing a diagnosis
• A practice nurse administering incorrect vaccinations or out-of-date medications to patients
• Clinical staff failing to follow up on test results
• An administrative delay in recalling a patient for results, and
• Results not being marked as notified within recalls.

Every aspect of your practice should be scanned for near misses. Patient files can be a minefield for near misses – with anything from accessing the incorrect patient file for similarly named patients to a patient’s address not confirmed when calling an ambulance for them.

Medical devices are also a ‘hotspot’ area for risks with clinical staff potentially not knowing how to use devices correctly, the devices not being properly cared for or maintained, or failing to undertake audits on treatment room stock, which may lead to malfunctions.

The RACGP’s 2014 publication, ‘Clinical risk management in general practice: A quality and safety improvement guide and educational resource for individual- or group-based learning’ is an excellent resource to help you identify and understand clinical risks and their solutions.

The guide gives several examples of near misses, pathways the clinical team could have gone through, and the severity of outcomes-based upon those pathways. See page 20 for resources to help you achieve quality improvement for information on where you can find the guide.

Clinical risk management within the RACGP Standards 5th edition

Most practitioners and practices already manage clinical risk daily. Many have informal and ad hoc methods aimed at preventing near misses and adverse events. Within the RACGP Standards, Criterion QI3.1 – Managing clinical risks, the following suggestions are offered to reduce near misses and adverse events:

• Establish a system so that practitioners talk to trusted peers and supervisors for advice
• Use a formal process of discussing within the practice what went wrong and how to reduce the likelihood of it happening again
• Use structured techniques to analyse the causes of near misses and adverse events to reduce the likelihood of recurrence
• Establish a system so that members of the practice team know-how and to whom to report a near miss or adverse event, and that they can do so without fear of recrimination
• Keep copies of the practice’s risk or critical incident register
• Implement a clinical governance framework to help achieve a balance of ‘find it’, ‘fix it’, and ‘confirm it’ function to improve the quality and safety of care
  • Find it – use tools such as clinical audits and performance indicators to identify where quality improvement programs could improve care and patient health outcomes
  • Fix it – after identifying where improvements can be made, implement strategies to address the issue, and
  • Confirm it – measure the outcomes of the improvement using an effective evaluation process.

While these are suggested ways to reduce clinical risks, the two Indicators within Criterion QI3.1 that are mandatory and are ‘musts’ for your practice.

QI3.1 A  > Our practice monitors, identifies, and reports near misses and adverse events in clinical care.

Your practice must implement and maintain an incident or event register. This is important as patient safety incidents in clinical care occur in all health settings.

If you use systems to recognise and analyse near misses and adverse events, you can identify, implement, and test solutions to prevent them from happening again.

You could implement and maintain a clinical risk management policy, such as the one provided as part of AGPAL’s Policy and Procedure Manual Template, found in your AGPAL accreditation hub.

Alternatively, your practice team could conduct clinical audits and make changes to clinical care to reduce the risk of identified issues or keep a record of team meetings and planning meetings where risks are discussed.

QI3.1  B > Our practice team makes improvements to our clinical risk management systems in order to prevent near misses and adverse events in clinical care.

You must record the actions taken in response to events recorded on the incident or event register. To show that you are doing this, your team could record revisions to policies and procedures that have been shown to reduce risk.

Access AGPAL’s clinical near miss and mistake register template to ensure your practice outlines the description of each near miss, the action to address it, action to prevent it, and an allocated person responsible for these actions.

Consistent use and application of a clinical risk management tool is important for patient care because:

• The same mistake can have different causes on different occasions.
• The causes of near misses and mistakes are identified and processes are improved to reduce the likelihood of them occurring again.
• Without improvements, patients may be exposed to an increased risk of adverse outcomes and the practice staff exposed to medico-legal action.
• Practices must demonstrate how and why they have made changes to improve clinical care.

Clinical Risk Management Resources

Login to your AGPAL accreditation hub to access the following:

• AGPAL clinical near miss and mistake register template
• AGPAL Policy and Procedure Manual Template – section 3.2 Incidents and injury and adverse patient events, and
• AGPAL webinar: Clinical Risk Management.
• RACGP Clinical Risk Management in General Practice (2014)