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Clinical Risk Management Health And Social Care Essay

Clinical Risk Management Health And Social Care Essay

The aim of this essay to provide the reader with insight to the word ‘clinical risk control’ and how this is applied within NHS trusts focusing particularly on the function of Pharmacists in doing this.


Defining ‘clinical risk management’ and discussing its importance

Discussing ways that trusts implement scientific risk management

Defining exactly what is a medication error and identifying the part of the pharmacist to lessen these

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

1.0 Importance of clinical risk management

Clinical governance was initially mentioned in British Wellbeing insurance policy in 1997 as a term used to spell it out the accountability techniques for clinical quality of treatment. It evolved as something to address and react to a series of visible media cases highlighting poor quality patient care as uncovered in the Nottingham IT vincristine disaster, Bristol Heart and soul operation, Shimpan and Alder Hey organ retention.

During I997 in England, the Department of Wellness published the light paper the ‘New NHS; modern, dependable’ which introduced Clinical governance as a method of accounting for medical quality in health care but really came to prominence in 1998 when Scally and Donaldson appraised ‘Clinical governance and the get for quality improvement in the NHS’ in the Uk Medical Journal. The paper highlighted four components of quality as initially discovered by the World Health Organisation:

Professional performance (technical top quality)

Resource use (efficiency)

Risk management (threat of injury or illness associated with the service provided)

Patient satisfaction with the assistance provided.

Majority of NHS treatment is of an extremely high standard and in comparison to the high volume of care provided on a daily basis in hospital and network, incidence of considerable failures are uncommon.1 However when they do occur, they have devastating effects for individual patients and family members.1 Greater patient targets, knowledge and media publicity of visible cases have resulted in the NHS becoming scrutinized focusing on its policies of procedure, facilities and operating culture.

It is estimated that an average of 850,000 adverse events might occur in the NHS hospital sector each year producing a £2billion immediate cost in additional hospital days by itself.1 Poor clinical efficiency results in patient damage and lack of patient’s assurance in the NHS providers as well as a rise in litigation costs.4 In 2009/10, 6,652 claims of medical negligence and 4,074 claims of non-clinical carelessness against NHS bodies had been received by the NHS Litigation Authority, up from 6,088 claims of clinical negligence and 3,743 promises of non-clinical carelessness in 2008/09.4 £787 million was paid out regarding the clinical carelessness claims during 2009/10, up from £769 million in 2008/09.4

Errors are discussed as either ‘human’ or ‘systematic’ in the Section of Health document ‘An organisation with a memory space’. As an NHS organisation the focus is systematic, a more holistic approach when dealing with errors. This process recognises the value of resilience within organisations and that mistakes result as several interacting factors and failures within the system.1

NHS Quality Improvement Scotland (NHS QIS) medical governance and risk supervision standards define risk operations as the:

Systematic identification and treatment of risk

Continuous process of reducing risk to organisations and people alike

Culture, operations and structures that happen to be directed towards realising potential opportunities whilst managing adverse events

In days gone by, clinical risk management was poorly managed in the NHS. There have been no individuals designated to control risk management, incident reporting in primary care was generally ignored, there is no standard approach to incident investigation, and existing systems didn’t facilitate learning across the NHS.1 In the 1990s there was a concerted drive to build up risk management and risk control within NHS organisations.1 Following on out of this there has been an elevated awareness of the cause of medication mistakes in NHS trusts and how these could be prevented.1 In 2000, the government made a commitment to lessen the rate of severe mistakes by 40%. The improvements in technology and know-how in recent years has resulted in a far more complex healthcare system.2 This complexity carries risks and proof indicates that things do and will go wrong in the NHS often resulting in patient harm.2

The NHS top quality improvement strategy1 encompasses;

Clear national quality expectations; NICE, NSF

Dependable local delivery; devices of clinical governance in NHS organisations

Strong monitoring mechanisms; a fresh statutory commission for health improvement, an NHS functionality assessment framework, and a national survey of NHS individual and user experience.

It is definitely hoped adaptation of the approaches in individual NHS organisations should have a positive effect on the production to detect, prevent and study from system failures at a local level.1 The launch of clinical governance provides NHS organisations with a powerful imperative to concentrate on tackling adverse healthcare events1. The time is right for a simple re-thinking of just how that the NHS approaches the difficulties of learning from a detrimental health care event.1

2.0 Implementing Risk Management within NHS trusts

The Department of Overall health publication ‘An organisation with a recollection’ facilitated the patient safety activity in the NHS.2 It proposed answers to risk administration incidences through a traditions of openness, reporting and protection consciousness within NHS organisations.2 Four Essential areas highlighted out of this report were:2

Unified mechanisms for reporting and research when things fail;

A more open customs where incidents or assistance failures can be reported and discussed;

Systems and monitoring procedures to ensure that where lessons are determined the necessary changes are placed into practice;

A much wider appreciation of the worthiness of the systems methodology in preventing, analyzing and learning from patient security incidents.

In response to an organisation with a recollection, the Government report Creating a safer NHS for sufferers focuses about how to implement these recommendations2. It outlined a blueprint for a nationwide Incident reporting program and discussed the position of the National Individual Safety Agency (NPSA).2 The NPSA was setup by the Section of Health in 2001 with the purpose of preventing harm from risky medicines. The NPSA generated the National Incident reporting and Learning program (NRLS) to set priorities, develop and disseminate actionable learning following studies of patient security incidents.

Following this direction all NHS trusts must have a risk management approach in place. This includes systems for the identification of most risks which may compromise delivery of patient care. To assist with this trusts are obliged to provide patient services in compliance with statutory regulations according to countrywide and regional requirements highlighting the level and quality of offerings required. The implementation of risk management guidelines within NHS trusts will get overseen by Clinical Governance managers and Risk managers4. Trust Risk supervision strategies will need to be regularly reviewed and audited; individual trusts will have Risk Managers within each section to oversee this4. The Trust Board will make sure that risk management, top quality and safety receive priority and the required resources within budgets.

Pharmacy departments will have a medicines management workforce comprising of a risk control pharmacist to apply risk management at an area level. The Risk operations pharmacist will ensure staff are aware of risk management problems both locally and nationally and will update staff on activities to be studied to minimise risk thus promoting compliance with exterior risk management standards. The risk management pharmacist may also must ensure local risk management plans are kept updated.

In order to provide the risk management agenda, specific trusts must meet up with the requirements of the NHS Litigation Authority Risk Control standards and the Care Quality Commission standard’s (CQC) from projectile motion graph medical and Social Action 2008. From April 2010, NHS providers should register with the CQC and offer proof adherence to standards set by the CQC5.

2.1 National Person safety company and National Reporting Learning System

In 2001, following publication of the Section of Health document and ‘Organisation with a Memory’1 the National Sufferer safety agency (NPSA) was create. The launch of the NPSA possesses for the very first time provided a systematic focus on medication safety6. The purpose of the NPSA is usually to lead and donate to improved, safe patient attention by informing, assisting and influencing organisations and persons working in the health sector with one core purpose – ‘to improve individual safety by reducing the chance of harm through mistake’7. The NPSA’s initiative was to recognize patterns and styles in avoidable adverse happenings in order that the NHS could put into practice changes to prevent these incidents from reoccurring.

The NPSA will 2, 8:

Collect and examine information a detrimental events in the NHS

Assimilate other safety-related information from a number of existing reporting systems

Learn lessons and ensure that they are fed back to practice

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

and establish mechanisms to track progress

The NPSA in that case went onto make the National Incident Reporting and Learning program (NRLS) which aims to identify and decrease the risks to patients getting NHS health care and leads on countrywide initiatives to improve patient safety. There are NHSLA risk control standards for every type of NHS healthcare organisation. The benchmarks will address medical and non-clinical health and safety risks.4 Individual trusts will come to be examined frequently and measured against expectations to make sure a risk management approach has been devised, it really is in place throughout the trust, it is workable.4 This will minimise litigation costs resulting in more funds open to trusts to improve patient care; providing an incentive for better scientific and non-clinical risk administration.

The NRLS collects confidential info on medication problems from all NHS trusts in England and Wales and enhances patient safety by allowing the NHS to understand from patient basic safety incidents8. This builds on incident reporting systems which were previously used on an adhoc basis in individual trusts. The NRLS reporting program has been made to be appropriate for local risk management systems that are used in majority of NHS organisations.2 NRLS studies happen to be analyzed by clinicians and safeness experts8 and key styles and trends adding to patient security incidents are identified.2 Steps are then taken to minimize these hazards through the production and prioritisation of countrywide solutions.

‘Trusts reporting incidents frequently suggest a more powerful organisational culture of security’.8 Encouraging personnel to report medical incidents affecting patient security can help implement risk management approaches within NHS trusts. The more incident studies submitted the more info available to swiftly identify and act upon patient protection incidents. The NRLS implies trusts ought to be submitting incident reports once a month.8 In pharmacy these will largely involve incidents relating to medication errors.

The development and promotion of the NHS ‘reasonable blame’ culture encouraged error reporting reassuring staff the root factors behind errors will be investigated. However, lack of awareness and concern with disciplinary action remain as a few of the key barriers to incident reporting.8 To conquer this staff ought to be adequately educated on when and how exactly to report clinical incidents. Within my base hospital, incident-reporting training is included in the trust induction and at a local pharmacy level as an in-house induction.

Each trust incident is graded relating to standardised NPSA scoring devices; 1 being minor without harm to individual ranging to catastrophic level 5 i.e. patient death. Following completion of an on the web incident form, the chance lead for that one area will receive a copy of the record. These reports will become analysed and appropriately graded and any severe incidents will then become reported to the Trust Board via the risk management committee.

A record by the NPSA explained the mostly reported drugs related incidents to be:8

Wrong dose, strength and frequency of medicines

Wrong medicine

Delayed and omitted doses

Medicine related incidents will become reported to the Risk Management pharmacist who’ll provide feedback to the pharmacy crew. All category 4 and 5 incidents have a complete root-cause analysis performed and are submitted to the NRLS. These reports are then analysed by the NPSA, and if necessary quick response alerts are developed.1, 8 Rapid response alerts become a crucial methods to focus the work of trust clinical risk managers into verified risky areas.8 Delayed and omitted doses of medication resulted in the production of a recently available speedy response alert. This alert was delivered to trusts by the NPSA via the NHS’s Central Alerting system.8 On receipt of the alert, trusts were expected to respond and act after requests included within it within the specified deadline furnished. Each alert contains recommendations for regular audits to be able to review the action taken.

3.0 Medication Errors

Most medication aren’t without adverse effects and most side effects and adverse occurrences are predictable, thus contact with these adverse events could be minimised or avoided through careful prescribing and usage. Nevertheless some undesireable effects are unpredictable and for that reason unavoidable.6 However medication errors occurring consequently of faults or lapses when prescription drugs are approved dispensed or used happen to be avoidable. These can be linked to practice, procedures, goods or systems. 6

Medication errors as defined by the NPSA are

‘any preventable event(s) that could cause or result in inappropriate medication use or patient harm while the medication is normally in the control of the health care professional, affected individual or consumer. Such occasions may be related to professional practice, health care products, procedures and systems, including prescribing; order communication; product labeling, product packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.’ 10

Numerous studies have already been conducted to investigate the incidence and outcomes of medication-related injury. A 2008 research conducted in an emergency section in Scotland found 2.7% of admissions were related to adverse drug reactions. 11 In 56.7% of conditions the adverse drug reaction was the documented reason for admission but only 13.3% were regarded as unavoidable.11 Another review carried out by Charles Vincent examined a lot more than 1000 records and discovered that 10.8% of individuals experienced a detrimental event and that 50 % of these were preventable.12 It had been found that a third of the adverse events resulted in either serious consequences or death.12 Medicine errors likewise occur in other healthcare systems, and is estimated harmful errors occur in 1.8% of hospital admissions in the United States, leading to about 7,000 deaths every year.6 Similarly, an Australian study revealed that 0.8% of inpatients suffered a unsafe medication error.6

3.1 Why perform medication errors occur?

To have the ability to reduce the risk of medication errors, the cause of medication errors must be understood.6 Previously medication errors were regarded as the sole responsibility of the persons considered to be the cause of the error. However, today a more holistic strategy is taken and it is acknowledged mistakes occur when both individual and system elements interact in a chain of occurrences – 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 Medical doctor and Professor at Harvan university of Public Health and wellbeing said:

‘Human beings make mistakes as the systems, tasks and functions they work in will be poorly designed.’ 6

Human factors derive from the individual and may occur due to lack of training and education and lapses in concentration. System errors result from the working of the organisation and the lack of policies and types of procedures in destination to reduce clinical risk. Latest experience shows in certain circumstances those safeguards have not been adequate and have didn’t prevent serious mistake and harm to the patient.6

Active failures and latent circumstances trigger holes in the defence program to open up.6

The lively failures occur as a result of unsafe procedures of the people working with a system, examples include the prescriber failing woefully to double check a prescription, or the pharmacist failing woefully to identify an incorrect dosage on a prescription.6 Latent conditions occur due to the composition of the organisation and its own resources, management and processes set up.6 These either alone or in blend with an active failure, can result in error. Examples include the lack of a computerised prescribing program with inbuilt devices to emphasize an erroneous prescription or having less an effective communication system between most important and secondary care.6

3.2 The role of the pharmacist in handling medication errors

Pharmacists as specialists in medicines have an invaluable part in reducing medication problems. As an occupation and experts in the careful utilization of medicines we are most effective located to minimise the dangers connected with medication usage.12

The government ‘safety of doses’ record recommended seven action 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 appropriately labeled gets to the patient.

Document patient allergy status.

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

Risk in the drugs itself.

Risk in the manufacture, storage space, and distribution of drugs.

Risk in make use of medicines.

Pharmacy departments all together are similar to top quality manufacturing units and test each level in the production, storage area and distribution of medications.12 Pharmacists are involved in virtually all stages of the medicine cycle from clinically verifying of the prescription to the reliability checking and final launching of the medicine dispensed. Within the pharmacy culture there may be the expectation for errors that occurs and consequently systems have already been developed and devote place to minimise these.12 Types of pharmacy services to lessen

medication related problems in hospitals are:12

Checking of prescriptions and supplying of drugs.

Ward drug charts.

Use of our know-how and pharmacokinetics to evaluate toxic and sub-therapeutic dosages.

Quality control and assurance measures.

3.2.1 Ward structured Pharmacy services

Pharmacy services at ward level had been initially proposed as a well being policy in 1970 and have proven to detect and prevent prescribing mistakes.12 The purpose of the pharmacist is certainly ever evolving and pharmacists have become recognised as a fundamental element of the multi-disciplinary workforce. The pharmacists function has shifted from the original ‘supply role’ to a more ‘clinical function’ allowing pharmacists to employ their consultant knowledge surrounding medication work with to reduce medication mistakes at ward level. Pharmacists are a lot more effective at ward level and as such are now the first slot of demand advice on medicine by patients and various other healthcare professionals. The pharmacist’s purpose also reaches medicines control and formulary development, medications information and involvement in various dispensing phases. Throughout these different functions the pharmacist’s remain energetic to advertise safer practice and reduction of medication errors.

3.2.2 Medicines Reconciliation

Medicines reconciliation is an activity designed to make sure that all medication a patient is currently taking is correctly documented on admission and at each transfer of care. It encompasses:




The National Institute for Health and Clinical Excellence (NICE) in collaboration with the NPSA released guidance to make sure appropriate procedures are in destination to assure any medication sufferers are taking ahead of admission is effectively documented on admission to medical center.8 The NPSA reported the amount of incidents of medication errors involving entrance and discharge as 7070 with 2 fatalities and 30 that caused extreme harm (statistics from November 2003 and March 2007).8 An accurate medication history is essential to assist safe prescribing.

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

pharmacists are involved in medicines reconciliation as quickly as possible after admission

the obligations of pharmacists and different staff in the medicines reconciliation process are clearly defined; these responsibilities may fraction to mixed number calculator differ between clinical areas

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

At my base medical center, medicines reconciliation consists of doctors, nurses, pharmacists and pharmacy professionals. Systems and policies are in spot to deliver medicines reconciliation in several areas of care and also to ensure all staff involved in the medicines reconciliation process are accredited and adequately trained.

3.2.3 Education and Training

At my base hospital information regarding medical risk management is greatly accessible to all staff through a number of sources; alongside co-operate clinical mandatory workout sessions and in-house local workout sessions, a multitude of information is on the neighborhood trust intranet. These include a governance newsletter entitled ‘Lessons Learned’ detailing adverse events that have occurred and steps taken to prevent reoccurrence of such incidents, risk management manuals available on-collection and the NPSA patient safety literature. At an area pharmacy level, the regular medicines management bulletin includes medication security updates and is distributed to all pharmacy staff.

As well as these steps education and training to other healthcare professionals and patients on medicine is paramount. Pharmacists are the professionals best placed to do this. The Central Manchester Base Trust took portion in a prescribing mistake audit referred to as the EQUIP review. This confirmed pharmacists as professionals in medications held invaluable expertise and through organised education programmes might help reduce medication errors.14 The main cause of prescribing errors amongst newly qualified medical staff was simply because of lack of knowledge regarding medicines.14 Results demonstrated the necessity for pharmacists at ward established level and preventing potentially serious medication errors through their presence on the ward.14 Pharmacists on wards offered medical staff immediate access to advice concerning dosing, interactions and therapeutic monitoring of medications.14 Pharmacists are likewise more likely to complete incident reports involving medicines and really should encourage other staff to accomplish the same. Ensuring staff are aware the only way to increase the systems set up is to learn what we are carrying out wrong.

Pharmacists are also involved with developing and delivering teaching sessions for various groups of staff. Examples included at my base hospital happen to be VTE prophylaxis, IV drug calculations and monitoring for unfractionated heparin. All Pharmacists are encouraged to deliver and attend teaching sessions early on in their career. And educating medical personnel, pharmacists counselling of people in outpatients and at discharge will also aid reduction in medication errors.

As very well as delivering data and teaching deals, pharmacists need to ensure information provided is sufficient, easily accessible or more to date. Medicine details pharmacists will analyze how best to provide information for secure prescribing and medicine administration.6 The formulation and dissemination of remedies policies and clinical recommendations by pharmacists contributes to risk management. Pharmacists likewise suggestions clinicians on risk issues due to quality assurance reports e.g. NPSA, nationwide and local clinical audit.4

3.3 Reduction in medication errors

Medication errors occur because of a variety of failures. Pharmacists clinically reviewing a prescription can identify and stop prescribing errors, but prescribing is only taking care of of the medication cycle.7 Failures in the functions of reviewing, dispensing, administering and monitoring of drugs as well occur.7 To conquer these adequate systems and checks to avoid medication errors need to be in place. Examples of such systems include:13

Effective communication

Education of all healthcare professionals

Integrated electronic care records

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

Providing a day medicines information offerings and support to medical staff

Increase specialists staff, more training for junior personnel from an undergraduate level and better discharge procedures

Development of it services and standardised electronic digital incident reporting systems

3.3.1 Information Technology

The developments of technical systems contain helped in the running of medicine based offerings and include automated dispensing systems and electronic prescribing. Comparable packagings of medications by the same manufacture cause frequent dispensing mistakes. The implementation of an automated dispensing robot in my trust has significantly reduced error costs through the incorrect selection of medication. In addition, it minimises administration problems through the creation of standard warning labels such as Methotrexate every week dosing warnings, and reminders to add ‘penicillin comprising’ stickers to relevant antibiotics. However, the system isn’t fool proof and therefore errors still occur mainly due to over reliance triggering staff to become deskilled. Close to miss audits to recognize potential mistakes are conducted regularly within my trust to highlight regions of concern and systems devote location to prevent these errors reoccurring.

Implementation of electric prescribing devices (medisec) for discharge and electronic digital dosage calculator on our neonatal product has also proven to reduce medication errors. Medication errors due to illegible handwriting no more occur minimising threat of dispensing errors. The option of drug name, dosage, formulation and dosing timetable have also reduced the chance of medication errors.7

3.3.2 Medication safeness at discharge

Poor communication between unique health care professionals can bring about medication problems at discharge. Drugs reconciliation on entrance has verified to be valuable in linking patient’s attention at primary care and secondary care. However, more focus needs to be placed on ensuring network pharmacists and GPs know about changes to medicine at the point of discharge. Improved connection will prevent GPs from prescribing drugs that are no longer indicated, contra-indicated or even duplicate prescription drugs.7 The execution of the electronic digital discharge program medisec and the automatic electronic copy of the discharge overview detailing information regarding medication changes has proven to be a useful tool in increasing communication to GPs, and maintaining the link between primary good care and secondary care. In addition to this, patients receiving a backup of their discharge overview and being counseled on the medication at the point of discharge will contribute to reducing medication errors.

4.0 Conclusion

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

Finite source – the NHS includes a limited amount of money and staff to supply a service

Complexity – the service we provide is extremely complex because of both the size and nature of the task

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

Clinical Risk Management can be an integral part of clinical governance and thus everyone’s business. Managers in every areas are responsible for ensuring that risks in the region are identified, monitored and controlled based on the Trust’s Risk Management Approach. This will contribute to improved delivery of products and services by providing a structured method of decision-making. . All staff employed in the NHS have got a responsibility to understand and implement risk control of their individual job functions. The advancement of technology, devices and operations and education of all staff will be the key to implement scientific risk management at native and national amounts in individual trusts.

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