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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).

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risk assessment
Risk Assessment

Dr Mike Rejman

Risk Assessment Adviser

how do accidents happen
How do Accidents Happen?

Organisation and processes

- Deficiencies

Prior conditions - basic causes

& contributory factors

“Unsafe” acts - active failures (SRK errors)



Patient Safety Incident

understanding the problem
Understanding the Problem
  • ~ 80% of accidents are attributable to human factors, at the individual level, the organisational level, or more commonly both
  • This is a conservative figure and is irrespective of domain
  • To manage this we need to identify and understand the risks (causes and contributory factors)
  • Without this we can’t put appropriate remedial action in place
seven steps to patient safety

Seven Steps to Patient Safety

  • Build a safety culture
  • 2. Lead and support your staff
  • 3. Integrate your risk management activity
  • 4. Promote reporting
  • 5. Involve patients and the public
  • 6. Learn and share safety lessons
  • Implement solutions to prevent harm
step 3 integrated risk management

Step 3 - Integrated Risk Management

All risk management functions and information:

patient safety,

health and safety,


clinical litigation,

employment litigation,

financial and environmental risk

Training, management, analysis, assessment and investigations

Processes and decisions about risks into business and strategic plans

risk assessment by donald rumsfeld

Risk Assessment by Donald Rumsfeld

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.

accidents serious incidents incidents near misses hazards





The Accident Iceberg


serious incidents


near misses

& hazards

prior indicators of risk
Prior Indicators of Risk
  • Challenger Space Shuttle
    • evidence of seals shrinking in cold temperatures, but political pressure to launch
  • Columbia Space Shuttle
    • long-standing problem with foam falling off (for 9 years)
    • even after Columbia disaster, a minority report noted at least 3 crucial issues not actioned
    • this endangered Discovery
identifying areas of risk
Identifying Areas of Risk
  • Retrospective – learn lessons
    • Accidents and incidents,
    • Root Cause Analysis
  • Prospective – anticipate issues
    • Reporting systems, near misses, reported hazards
    • Prospective Risk Assessments, (proactive hazard assessment)
some risk assessment methods

(Healthcare) Failure Modes and Effects Analysis


Hazard and Critical Control Points


Hazard and Operability Studies


Probabilistic Risk Assessment


Structured ‘What If’ Technique

HRA Techniques


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 System

Some Risk Assessment Methods
risk assessment methods
There are a great many methods

Most were developed in safety-critical industries other than healthcare, only a few have been adapted to healthcare, with mixed success

Problems over

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
risk assessment methods18
NPSA is developing two approaches to the issue –

(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-term

Risk Assessment Methods
risk assessment s four basics questions

How bad

could this

be ?

Is there a

need for


if so what?

What could

go wrong?

How often?

Risk Assessment’s Four Basics Questions
lead to four management options
Lead to Four Management Options
  • Terminate
  • Treat
  • Tolerate
  • Transfer
  • Structured ‘What IF’ checklisT
  • Good technique for considering both human and organisational factors, as well as equipment factors, that may affect safety
  • Structure
  • Identification driven by:
    • Question driven
      • What-if ………?
    • Checklist
  • Best done using a multi-professional group
risk assessment flow diagram australian new zealand model

Establish the Context

Identify Risks

Analyse Risks



Risk Assessment

Level of Risk

Monitor and Review

Communicate and Consult

Evaluate Risks


Accept Risks?


Treat Risks

Risk Assessment Flow DiagramAustralian/New Zealand model
  • Risk assessment is a “PROCESS”
  • Helps to determine if systems, facilities or activities are acceptable
  • Aid to decision making
risk matrices
Risk Matrices
  • Used for:
    • Qualitative assessment of the level of risk from an event
  • Commonly used in risk assessments
  • Found in many forms
risk matrix
Risk Matrix
  • Two dimensions
    • Consequence
      • (Also commonly called impact or severity)
    • Likelihood
      • (Also commonly called frequency or probability)
  • How to use
    • Define for a risk:
      • Its consequence
      • Its likelihood
    • Read off the risk level



Consequence / Severity / Impact

how to use a risk matrix
How to Use a Risk Matrix
  • Identification of hazardous event/scenario
  • Determining the risk using a risk matrix
    • Assessment of the event’s/scenario’s consequence
    • Assessment of the event’s/scenario’s likelihood of occurrence
    • Determination of risk, (plotting scenarios on the risk matrix)
  • Risk evaluation and decision making
how to use a risk matrix27
How to Use a Risk Matrix
  • Assessment of the event’s/scenario’s consequence
    • May be a range of possible outcomes
    • If possible chose outcome which is of regular concern
    • (Otherwise assess risk for different outcomes)
how to use a risk matrix28
How to Use a Risk Matrix
  • Assessment of the event’s/scenario’s likelihood
    • Note that the likelihood is for the outcome being considered
    • Common error is to match event likelihood with worst case outcome which only happen in a minority of the event outcomes
how to use a risk matrix29
How to Use a Risk Matrix
  • Determination of risk
    • Plot scenario on the risk matrix
risk evaluation and decision making
Risk Evaluation and Decision Making
  • The risk classes help drive risk mitigation decision making
  • Common approach:
    • Where the risk is assessed as:
      • “Low”
        • Evaluate as tolerable
        • No risk mitigation recommendations needed
      • “High”
        • Evaluate as intolerable
        • Risk reduction is required - aim to reduce medium or low
      • “Medium”
        • Evaluate as tolerable if ALARP demonstrated
        • Practical and cost effective recommendations to reduce risk needed
for example it systems
For Example - IT Systems
  • Introducing IT systems can greatly increase capacity AND help eradicate certain errors


  • Unless systems are carefully designed to take account of human factors, they can actually increase errors and even introduce new ones, with catastrophic consequences
new technology in airbus 320
New Technology in Airbus 320
  • ‘Glass cockpit’ and ‘fly by wire’ state of the art technology
  • Multifunction displays with many ‘pages’ some of which are remarkably similar
  • Operator awareness issues - leading to the introduction of a new error - ‘mode error’
  • 87 people died in a crash at Strasbourg
results from npsa funded study on gp it systems university of nottingham
Results from NPSA Funded Study on GP IT Systems (University of Nottingham)
  • Allergy alert may not be generated
  • Hazard alert generated every third prescription
    • Single keystroke to over-ride alert
    • No audit trail
  • Not all safety functionality activated (e.g. contra-indications)
  • Hazards generated by drop-down menus (wrong selection made – awareness)
  • GPs unsure of safety functionality on systems
    • Some think functionality is present when it isn’t (e.g. contra-indications)
risk assessment35
Risk Assessment

To ensure safe operation …

Systems and Processes need:

  • To be well designed (human factors) and thoroughly risk assessed
  • To be more intuitive
  • To make wrong actions more difficult
  • To make correct actions easier (telling people to be more careful doesn’t work)
  • And it should be easier to discover error
hospital at night han risk assessment guide
Hospital at Night (HaN) Risk Assessment Guide
  • Presents an approach to risk assessing Hospital at Night solutions
  • Available on the NPSA web site