Risk Assessment. Dr Mike Rejman Risk Assessment Adviser. Why do Accidents Happen?. Why do Accidents Happen?. How do Accidents Happen?. Organisation and processes - Deficiencies. Prior conditions - basic causes & contributory factors. “Unsafe” acts - active failures (SRK errors).
Dr Mike Rejman
Risk Assessment Adviser
Organisation and processes
Prior conditions - basic causes
& contributory factors
“Unsafe” acts - active failures (SRK errors)
Patient Safety Incident
All risk management functions and information:
health and safety,
financial and environmental risk
Training, management, analysis, assessment and investigations
Processes and decisions about risks into business and strategic plans
As we know,
There are known knowns.
There are things we know we know.
We also know there are known unknowns.
That is to say
We know there are some things we know we do not know.
But there are also unknown unknowns -
The ones we don’t know we don’t know.
The Accident Iceberg
(Healthcare) Failure Modes and Effects Analysis
Hazard and Critical Control Points
Hazard and Operability Studies
Probabilistic Risk Assessment
Structured ‘What If’ Technique
Human Error Analysis and Reduction Technique
Technique for Human Error Prediction
Systematic Human Error Reduction and Prediction Approach
Generic Error Modelling System
Influence Diagram Error Analysis SystemSome Risk Assessment Methods
Most were developed in safety-critical industries other than healthcare, only a few have been adapted to healthcare, with mixed success
some quantitative, some qualitative
whether they can combine factors or only treat them independently,
issues over ‘number’ generation
few experimental comparisons, validation, or guidance
some very resource intensive
Which one to use?Risk Assessment Methods
(i) Patient Safety Research Fund – longer term research to identify the best methods for healthcare and adapt methods if necessary. Will take 2+ years to produce a toolbox
(ii) ‘Fast track’ pragmatic approach to produce guidance in the short-termRisk Assessment Methods
Level of Risk
Monitor and Review
Communicate and Consult
Treat RisksRisk Assessment Flow DiagramAustralian/New Zealand model
Consequence / Severity / Impact
To ensure safe operation …
Systems and Processes need: