Clinical Risk Management Health And Social Care Essay

The aim of this essay to provide the reader with insight to the term ‚clinical risk operations‘ and how this is applied within NHS trusts concentrating particularly on the function of Pharmacists by doing this.


Defining ‚clinical risk management‘ and discussing its importance

Discussing ways in which trusts implement scientific risk management

Defining exactly what is a medication mistake and identifying the role of the pharmacist to reduce these

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

1.0 Importance of clinical risk management

Clinical governance was first mentioned in British Overall health policy in 1997 as a term used to describe the accountability processes for clinical quality of attention. It evolved as something to address and respond to a series of high profile media cases highlighting low quality patient care as uncovered in the Nottingham It all vincristine disaster, Bristol Center medical procedures, Shimpan and Alder Hey organ retention.

During I997 in England, the Division of Well being published the bright white paper the ‚New NHS; modern, reliable‘ which launched Clinical governance as a method of accounting for clinical quality in health care but really came to prominence in 1998 when Scally and Donaldson appraised ‚Clinical governance and the travel for top quality improvement in the NHS‘ in the Uk Medical Journal. The paper highlighted four pieces of quality as primarily recognized by the World Overall 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 program provided.

Majority of NHS care and attention is of a very high standard and compared to the high level of care provided on a daily basis in hospital and sample capstone paper community, incidence of serious failures are uncommon.1 However when they do appear, they have devastating effects for individual people and family members.1 Greater patient anticipations, knowledge and media exposure of high profile cases have resulted in the NHS staying scrutinized focusing on its policies of procedure, facilities and operating tradition.

It is estimated an average of 850,000 adverse events may occur in the NHS medical center sector each year producing a £2billion direct cost in additional hospital days only.1 Poor clinical functionality results in patient injury and lack of patient’s self-confidence in the NHS providers as well as an increase in litigation costs.4 In 2009/10, 6,652 claims of medical negligence and 4,074 claims of non-clinical negligence against NHS bodies were received by the NHS Litigation Authority, up from 6,088 statements of clinical negligence and 3,743 promises of non-clinical carelessness in 2008/09.4 £787 million was paid case study method out regarding the clinical carelessness claims during 2009/10, up from £769 million in 2008/09.4

Errors are mentioned as either ‚human‘ or ’systematic‘ in the Division of Health record ‚An organisation with a recollection‘. As an NHS organisation the emphasis is systematic, a more holistic approach when working with errors. This approach recognises the value of resilience within organisations and that mistakes result as a number of interacting elements and failures within the system.1

NHS Top quality Improvement Scotland (NHS QIS) scientific governance and risk control standards define risk supervision as the:

Systematic identification and treatment of risk

Continuous process of minimizing risk to organisations and people alike

Culture, processes and structures that will be directed towards realising potential options whilst managing adverse events

In the past, clinical risk operations was poorly managed in the NHS. There have been no individuals designated to control risk management, incident reporting in principal care was generally ignored, there is no standard approach to incident investigation, and existing devices didn’t facilitate learning across the NHS.1 In the 1990s there is a concerted drive to develop risk administration and risk supervision within NHS organisations.1 Following on from this there has been an increased awareness of the reason for medication problems in NHS trusts and how these can be prevented.1 In 2000, the federal government made a commitment to reduce the rate of major mistakes by 40%. The improvements in technology and know-how in recent decades has resulted in a more complex healthcare system.2 This complexity carries hazards and data indicates that factors do and will go wrong in the NHS sometimes resulting in patient harm.2

The NHS top quality improvement strategy1 encompasses;

Clear national quality criteria; NICE, NSF

Dependable local delivery; devices of clinical governance in NHS organisations

Strong monitoring mechanisms; a new statutory commission for well being improvement, an NHS effectiveness evaluation framework, and a nationwide survey of NHS individual and user experience.

It is hoped adaptation of the approaches in individual NHS organisations must have a positive impact on the production to detect, prevent and learn from system failures at a local level.1 The introduction of clinical governance provides NHS organisations with a robust imperative to concentrate on tackling adverse health care events1. It’s high time for a simple re-thinking of just how that the NHS approaches the problems of learning from an adverse health care event.1

2.0 Implementing Risk Management within NHS trusts

The Department of Health and wellbeing publication ‚An organisation with a memory space‘ facilitated the individual safety movement in the NHS.2 It proposed solutions to risk management incidences through a lifestyle of openness, reporting and security awareness within NHS organisations.2 Four Key element areas highlighted out of this report were:2

Unified mechanisms for reporting and research when things fail;

A more open tradition in which incidents or support failures could be reported and discussed;

Systems and monitoring operations to make sure that where lessons are recognized the necessary changes are placed into practice;

A very much wider appreciation of the worthiness of the systems methodology in preventing, examining and learning from patient protection incidents.

In response to an organisation with a storage, the Government report Creating a safer NHS for individuals focuses on how to implement these suggestions2. It outlined a blueprint for a countrywide Incident reporting system and discussed the position of the National Sufferer Safety Agency (NPSA).2 The NPSA was create by the Department of Health in 2001 with the purpose of preventing harm from risky medicines. The NPSA created the National Incident reporting and Learning program (NRLS) to set priorities, develop and disseminate actionable learning following studies of patient protection incidents.

Following this instruction all NHS trusts should have a risk management technique in place. This includes devices for the identification of all risks which may compromise delivery of person care. To assist with this trusts happen to be obliged to provide patient solutions in compliance with statutory rules according to countrywide and localized requirements highlighting the level and quality of solutions required. The implementation of risk management plans within NHS trusts will become overseen by Clinical Governance managers and Risk managers4. Trust Risk management strategies will need to be on a regular basis reviewed and audited; individual trusts will have Risk Managers within each department to oversee this4. The Trust Board will make sure that risk management, quality and safety receive concern and the necessary resources within budgets.

Pharmacy departments will have a medicines management staff comprising of a risk control pharmacist to implement risk management at a local level. The Risk administration pharmacist will ensure personnel know about risk management issues both locally and nationally and will update staff on activities to be studied to minimise risk thus promoting compliance with external risk management standards. The chance management pharmacist will also must ensure local risk management guidelines are kept up-to-date.

In order to provide the risk management agenda, specific trusts must meet the requirements of the NHS Litigation Authority Risk Operations standards and the Good care Top quality Commission standard’s (CQC) from the Health and Social Action 2008. From April 2010, NHS providers will need to sign-up with the CQC and provide proof of adherence to standards placed by the CQC5.

2.1 National Individual safety agency and National Reporting Learning System

In 2001, following a publication of the Section of Health record and ‚Organisation with a Recollection’1 the National Patient safety organization (NPSA) was create. The intro of the NPSA features for the very first time provided a systematic focus on medication safety6. The aim of the NPSA is usually to lead and contribute to improved, safe patient care by informing, assisting and influencing organisations and people working in medical sector with one key purpose – ‚to improve individual safety by reducing the chance of harm through mistake’7. The NPSA’s initiative was to identify patterns and tendencies in avoidable adverse situations in order that the NHS could put into practice changes to avoid these incidents from reoccurring.

The NPSA will 2, 8:

Collect and examine information a detrimental events in the NHS

Assimilate other safety-related info from various existing reporting systems

Learn lessons and make sure that they are fed back to practice

Where dangers are identified, produce solutions to prevent harm, specify nationwide goal

and establish mechanisms to track progress

The NPSA then simply went onto produce the National Incident Reporting and Learning program (NRLS) which aims to identify and reduce the risks to patients getting NHS treatment and leads on national initiatives to boost patient safety. There happen to be NHSLA risk administration standards for each type of NHS health care organisation. The benchmarks will address scientific and non-clinical health and safety risks.4 Specific trusts will become examined frequently and measured against specifications to make sure a risk management technique has been devised, it really is in place through the entire trust, it really is workable.4 This will minimise litigation costs leading to more funds available to trusts to improve patient care; providing an incentive for better clinical and non-clinical risk operations.

The NRLS collects confidential info on medication problems from all NHS trusts in England and Wales and increases patient safety by allowing the NHS to learn from patient safe practices incidents8. This builds on incident reporting systems that were used on an adhoc basis in individual trusts. The NRLS reporting system has been designed to be compatible with local risk management devices that are being used in majority of NHS organisations.2 NRLS studies happen to be analyzed by clinicians and protection experts8 and key styles and trends contributing to patient safeness incidents are identified.2 Steps are then taken to minimize these dangers through the advancement and prioritisation of nationwide solutions.

‚Trusts reporting incidents frequently suggest a stronger organisational culture of basic safety‘.8 Encouraging staff to report clinical incidents affecting patient safety might help implement risk management strategies within NHS trusts. The extra incident information submitted the more info available to swiftly identify and act after patient protection incidents. The NRLS suggests trusts should be submitting incident reports monthly.8 In pharmacy these will mostly involve incidents relating to medication errors.

The development and advertising of the NHS ‚fair blame‘ culture encouraged mistake reporting reassuring staff the main factors behind errors will be investigated. However, lack of awareness and fear of disciplinary actions remain as a few of the primary barriers to incident reporting.8 To overcome this staff should be adequately taught on when and how exactly to report clinical incidents. Within my base hospital, incident-reporting training is included in the trust induction and at an area pharmacy level as an in-house induction.

Each trust incident can be graded in accordance to standardised NPSA scoring devices; 1 being minor with no harm to affected person ranging to catastrophic level 5 i.e. affected individual death. Following a completion of an on-line incident form, the chance lead for that particular area will get a copy of the statement. These reports will end up being analysed and appropriately graded and any major incidents will then get reported to the Trust Plank via the risk management committee.

A article by the NPSA mentioned the mostly reported drugs related incidents to be:8

Wrong dose, durability and frequency of medicines

Wrong medicine

Delayed and omitted doses

Medicine related incidents will become reported to the chance Management pharmacist who will provide responses to the pharmacy group. All category 4 and 5 incidents have a complete root-cause analysis performed and so are submitted to the NRLS. These reports are in that case analysed by the NPSA, and if necessary fast response alerts are generated.1, 8 Quick response alerts act as a crucial methods to focus the attempts of trust scientific risk managers into tested risky areas.8 Delayed and omitted doses of medicine resulted in the production of a recent speedy response alert. This alert was sent to trusts by the NPSA via the NHS’s Central Alerting program.8 On receipt of this alert, trusts were likely to respond and act after requests included within it within the specified deadline provided. Each alert contains recommendations for regular audits as a way to review the actions taken.

3.0 Medication Errors

Most medication aren’t without adverse effects & most side effects and adverse situations are predictable, thus contact with these adverse events can be minimised or prevented through mindful prescribing and usage. On the other hand some adverse effects are unpredictable and therefore unavoidable.6 However medication errors occurring consequently of problems or lapses when medications are prescribed dispensed or used will be avoidable. These could be related to practice, procedures, products or systems. 6

Medication errors as defined by the NPSA are

‚any preventable event(s) that may cause or bring about inappropriate medication employ or patient harm while the medication is certainly in the control of the health care professional, affected individual or consumer. Such incidents may be related to professional practice, healthcare products, procedures and systems, including prescribing; order connection; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.‘ 10

Numerous studies have been conducted to investigate the incidence and outcomes of medication-related harm. A 2008 review conducted within an emergency department in Scotland found 2.7% of admissions were linked to adverse drug reactions. 11 In 56.7% of situations the adverse drug response was the documented reason for admission but only 13.3% were considered to be unavoidable.11 Another study completed by Charles Vincent examined more than 1000 records and discovered that 10.8% of sufferers experienced an adverse event and that 1 / 2 of the were preventable.12 It had been discovered that a third of these adverse events resulted in either serious outcomes or death.12 Medicine errors likewise occur in other healthcare systems, and is estimated damaging errors occur in 1.8% of hospital admissions in america, leading to about 7,000 deaths each year.6 Likewise, an Australian study revealed that 0.8% of inpatients suffered a harmful medication error.6

3.1 Why do medication errors occur?

To manage to reduce the risk of medication errors, the cause of medication errors need to be understood.6 Previously medicine errors were regarded as the sole responsibility of the individuals considered to be the cause of the error. However, right now a more holistic methodology is taken and it is acknowledged problems occur when both human being and system factors interact in a chain of incidents – often complex- leading to an unhealthy outcome.6 Not only the individual at fault but latent conditions within an organisation and triggering factors in clinical practice also needs to be looked at as important factors behind error aswell.6 As Lucian Leape, the Doctor and Professor at Harvan school of Public Health and wellbeing said:

‚Human beings make faults because the systems, tasks and operations they work in are badly designed.‘ 6

Human factors result from the individual and may occur due to lack of training and education and lapses in focus. System errors result from the functioning of the organisation and the lack of policies and techniques in spot to reduce clinical risk. Latest experience shows in certain circumstances those safeguards have not been enough and have didn’t prevent serious error and injury to the patient.6

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

The lively failures occur consequently of unsafe practices of the persons working with something, examples include the prescriber failing woefully to double check a prescription, or the pharmacist failing woefully to identify an incorrect dose on a prescription.6 Latent conditions occur due to the composition of the organisation and its resources, management and techniques in place.6 These either only or in mixture with a dynamic failure, can lead to error. Examples include having less a computerised prescribing system with inbuilt devices to emphasize an erroneous prescription or having less a highly effective communication system between principal and secondary care.6

3.2 The role of the pharmacist in managing medication errors

Pharmacists as specialists in medicines have a great purpose in reducing medication errors. As a profession and professionals in the careful usage of medicines we are very best located to minimise the dangers associated with medication usage.12

The authorities ’safety of doses‘ article recommended seven actions points to boost medication safety. They are:13

Increase reporting and learning from medicine incident.

Implementation and audit of NPSA medication alerts guidance.

Improve staff training and competence.

Minimising dose errors.

Ensure medicines certainly not omitted.

Ensure correct medicine correctly labeled gets to the patient.

Document patient allergy position.

The three regions of focus in medication error decrease for Pharmacists to find and prevent are:12

Risk in the treatments itself.

Risk in the produce, safe-keeping, and distribution of medicines.

Risk in use of medicines.

Pharmacy departments all together are similar to high quality manufacturing units and check each level in the production, safe-keeping and distribution of medications.12 Pharmacists get excited about virtually all stages of the medication cycle from clinically verifying of the prescription to the reliability checking and final release of the medication dispensed. Within the pharmacy way of life there may be the expectation for errors that occurs and consequently systems have been developed and put in destination to minimise these.12 Examples of pharmacy services to reduce

medication related mistakes in hospitals are:12

Checking of prescriptions and providing of drugs.

Ward drug charts.

Use of our understanding and pharmacokinetics to examine toxic and sub-therapeutic dosages.

Quality control and assurance actions.

3.2.1 Ward based mostly Pharmacy services

Pharmacy offerings at ward level were initially proposed as a wellness policy in 1970 and also have proven to detect preventing prescribing mistakes.12 The role of the pharmacist can be ever before evolving and pharmacists have become recognised as a fundamental element of the multi-disciplinary group. The pharmacists role has moved on from the traditional ’supply role‘ to a far more ‚clinical position‘ allowing pharmacists to use their professional knowledge surrounding medication use to reduce medication errors at ward level. Pharmacists will be a lot more active at ward level and as such are now the first port of demand advice on medication by patients and different healthcare professionals. The pharmacist’s role also extends to medicines management and formulary development, medicines information and involvement in a variety of dispensing phases. Throughout these different functions the pharmacist’s remain lively to advertise safer practice and reduction of medication errors.

3.2.2 Medicines Reconciliation

Medicines reconciliation is an activity designed to make certain that all medication a patient happens to be taking is properly documented on entrance and at each transfer of attention. It encompasses:




The National Institute for Health and Clinical Excellence (Great) in collaboration with the NPSA released guidance to make sure appropriate processes are in place to assure any medication clients are taking just before admission is effectively documented on admission to hospital.8 The NPSA reported the number of incidents of medication problems involving entrance and discharge as 7070 with 2 fatalities and 30 that caused serious harm (figures from November 2003 and March 2007).8 A precise medication history is essential to assist safe prescribing.

To improve medicines reconciliation at hospital admission NICE/NPSA has suggested that:8

pharmacists get excited about medicines reconciliation as quickly as possible after admission

the duties of pharmacists and other staff in the medicines reconciliation process are plainly defined; these responsibilities varies between clinical areas

strategies are incorporated to acquire information about medications for people with communication difficulties.

At my base hospital, medicines reconciliation entails doctors, nurses, pharmacists and pharmacy technicians. Systems and guidelines are in spot to deliver medicines reconciliation in different areas of care and to ensure all staff involved in the medicines reconciliation method are accredited and adequately trained.

3.2.3 Education and Training

At my base medical center information regarding scientific risk management is greatly accessible to all or any staff through a number of sources; alongside co-operate scientific mandatory workout sessions and in-house local workout sessions, a multitude of information is on the local trust intranet. These include a governance newsletter entitled ‚Lessons Discovered‘ detailing adverse situations which have occurred and steps taken to stop reoccurrence of such happenings, risk management manuals available on-collection and the NPSA individual safety literature. At a local pharmacy level, the regular monthly medicines management bulletin includes medication security updates and is distributed to all or any pharmacy staff.

As very well as these procedures education and training to other health care professionals and sufferers on medicine is paramount. Pharmacists are the professionals best placed to get this done. The Central Manchester Foundation Trust took portion in a prescribing mistake audit known as the EQUIP review. This showed pharmacists as authorities in medicines held invaluable understanding and through organised education programmes can help reduce medication errors.14 The main cause of prescribing errors amidst newly qualified medical personnel was simply because of lack of knowledge regarding medicines.14 Results demonstrated the necessity for pharmacists at ward established level and the prevention of potentially serious medication problems through their presence on the ward.14 Pharmacists on wards offered medical staff immediate access to advice relating to dosing, interactions and therapeutic monitoring of prescription drugs.14 Pharmacists are as well much more likely to complete incident reviews involving medicines and really should encourage other staff to accomplish the same. Ensuring personnel are aware the only way to increase the systems set up is to learn what we are undertaking wrong.

Pharmacists are also involved in developing and delivering teaching sessions for various groups of staff. Examples included within my base hospital happen to be VTE prophylaxis, IV medicine calculations and monitoring for unfractionated heparin. All Pharmacists should deliver and attend teaching sessions early on in their career. As well as educating medical personnel, pharmacists counselling of clients in outpatients and at discharge may also aid reduction in medication errors.

As very well as delivering details and teaching deals, pharmacists must ensure information provided is sufficient, easily accessible and up to date. Medicine data pharmacists will analyze how best to provide information for safe prescribing and medicine administration.6 The formulation and dissemination of medicine policies and clinical suggestions by pharmacists contributes to risk management. Pharmacists likewise guidance clinicians on risk concerns arising from quality assurance reviews e.g. NPSA, national and local medical audit.4

3.3 Decrease in medication errors

Medication errors occur because of several failures. Pharmacists clinically reviewing a prescription can discover and stop prescribing errors, but prescribing is merely one aspect of the medication cycle.7 Failures in the processes of reviewing, dispensing, administering and monitoring of medications also occur.7 To overcome these satisfactory systems and checks to avoid medication errors must be in place. Types of such systems include:13

Effective communication

Education of all healthcare professionals

Integrated electronic care records

Systems and policies in place for purchasing, dispensing, administering and transporting in medicines

Providing 24 hours medicines information solutions and support to medical staff

Increase professionnals staff, more training for junior personnel from an undergraduate level and improved discharge procedures

Development of information technology services and standardised electronic digital incident reporting systems

3.3.1 Information Technology

The developments of technical systems have got helped in the running of medicine based services and include automated dispensing devices and electronic prescribing. Related packagings of medicines by the same produce result in frequent dispensing errors. The execution of an automated dispensing robot in my trust has substantially reduced error prices through the incorrect selection of medication. It also minimises administration errors through the production of standard warning labels such as for example Methotrexate weekly dosing warnings, and reminders to attach ‚penicillin made up of‘ stickers to relevant antibiotics. However, the machine isn’t fool proof and therefore errors still occur due mainly to over reliance creating staff to be deskilled. In close proximity to miss audits to identify potential problems are conducted regularly in my trust to highlight regions of concern and systems devote destination to prevent these problems reoccurring.

Implementation of electric prescribing systems (medisec) for discharge and electric medication dosage calculator on our neonatal device has also proven to lessen medication errors. Medication problems because of illegible handwriting no more occur minimising risk of dispensing errors. The availability of drug name, dose, formulation and dosing plan have also reduced the risk of medication errors.7

3.3.2 Medication safeness at discharge

Poor communication between different healthcare professionals can lead to medication problems at discharge. Medications reconciliation on entrance has confirmed to be useful in linking patient’s health care at primary health care and secondary care. On the other hand, more focus needs to be placed on ensuring network pharmacists and GPs are aware of changes to medication at the idea of discharge. Improved conversation will prevent GPs from prescribing medicines that are no more indicated, contra-indicated and even duplicate medicines.7 The implementation of the digital discharge system medisec and the automated electronic backup of the discharge summary detailing information regarding medication changes has proven to be a useful tool in improving communication to GPs, and maintaining the link between primary care and attention and secondary care. In addition to this, patients receiving a duplicate of their discharge overview and being counseled on the medication at the idea of discharge will contribute to reducing medication errors.

4.0 Conclusion

The have to manage risks is specially important in the NHS because of:

Finite resource – the NHS has a limited amount of money and staff to provide a service

Complexity – the service we provide is extremely complex as a result of both size and nature of the task

Expectation – we strive to meet up with the expectations of an increasingly aware public

Clinical Risk Management can be an integral part of scientific governance and so everyone’s business. Managers in every areas are in charge of making certain risks in the region are determined, monitored and controlled in line with the Trust’s Risk Management Approach. This will donate to improved delivery of services by giving a structured approach to decision-making. . All staff working in the NHS include a responsibility to understand and implement risk operations within their individual job roles. The production of technology, devices and processes and education of all staff could be the key to implement medical risk management at localized and national amounts in individual trusts.

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