SECTION: / EFFECTIVE DATE: October 1, 2006
SUBJECT:
Proactive Risk Assessment Policy / PAGE 1 of 8

Scope:

This policy applies to all direct and indirect patient care processes, departments, and facilities of ABC Medical Center (ABC).

Objective:

To establish a comprehensive, proactive risk assessment process to evaluate the potential adverse impact of direct and indirect patient care processes, buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and other people coming to ABC. This proactive risk assessment process is used to identify, rate, and prioritize risks and or hazards. Based on this risk assessment, policies, procedures, and controls may be put into place to manage the risks as appropriate to the organization, with the intent of reducing them to the lowest possible level.

Policy:

ABC conducts proactive risk assessments to identify and evaluate the potential of adverse impacts ofdirect and indirect patient care processes, buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and other visitors. Risk assessments are performed on identified hazards and proposed changes to new or existing processes. Examples of proposed changes include automated or manual work processes and equipment or other technology.

The goal of performing risk assessments is to reduce the likelihood of or mitigate the impact of incidents or other negative experiences that have the potential to result in injury, accident, or other loss to patients, visitors, staff, or assets.

It is important to understand that no process, activity, or system can ever be made completely risk free. Some level of risk is always present. The concept of risk assessment involves examination of the risks and making a determination as to what level of risk is acceptable to the organization. With limited resources, the object of risk assessment is to manage the risks in a prioritized fashion.

Ultimately, ABC’s leadership is responsible to determine the acceptable level of risk. If the level of risk is determined to be unacceptable, the risk must be removed, controlled, or reduced to an acceptable level for the process or activity to continue.

Results of the risk assessment process and other potential safety issues are reported and discussed in the Patient Safety Committee (Patient Safety) meetings. In the Patient Safety process, recommendations on management of the issue at hand are reached based on the committee’s evaluation of the situation and the pertinent data. This information may be used to create or revise policies, procedures, and practices, as well as develop orientation and education programs and performance monitors.

Procedure:

  1. The first step of the risk assessment process involves identifying potential risks to be the subject or target of the assessment process. Risks may be discovered as a result of incident reports, near misses, and environmental tours which are used to uncover environmental deficiencies, hazards, and unsafe practices. Potential hazards that are identified and do not involve simple corrections are candidates for risk assessment.

Additional sources of potential risk identification may include:

  • Issues reported to or identified by the Patient Safety Officer
  • Observations by any staff member
  • Published reports in the healthcare literature
  • New regulatory issues
  • JCSentinel events alerts
  • Product recalls
  • Inspections from outside agencies, insurance carriers, consultants
  • Internal events /Incident reports: injuries, accidents
  • A staff member concern that is brought to the attention of their department manager, thePatient Safety Officer, or any Patient SafetyCommittee member
  • Any source that identifies a potential risk
  1. The Patient SafetyOfficer will schedule departmental and area risk assessments by determining if any areas not scheduled for an initial assessment in a given year have had significant changes that would indicate the need to conduct a risk assessment in that area.
  1. Once a potential risk is identified, the Patient Safety Officer will present the issue for discussion at the next Patient SafetyCommittee meeting.
  1. The Patient SafetyCommittee will discuss the risk and if appropriate, appoint a risk assessment team to analyze the risk and report their findings at the next Patient SafetyCommittee meeting.
  1. The Patient Safety Officer will train the risk assessment team members on the proactive risk assessment process and how to conduct a proactive risk assessment, including the assessment of risk, itself.
  1. The risk assessment team will conduct an inspection of the department/area being assessed for risk or observe the process being assessed for risk in action. The members of the risk assessment team will individually document their findings on the “ABCProactive Risk Assessment Worksheet” (Attachment A). To determine the appropriate score for each identified risk, the reviewer will consider information obtained through a physical tour of the facility, review of annual incident and accident statistics, review of at least the past twelve (12) months Patient SafetyCommittee meeting minutes, hazard surveillance reports, interviews with department heads, and on-unit interviews with a representative sampling of staff. A proactive risk assessment may require more than one visit. In the event there is significant risk, visit frequency will be determined on an individual basis.
  1. The risk assessment team members will then meet to compare their results and, using multi-voting technique, agree on a single set of results for the risk assessment. The team will determine the risk score based on the probability and impact on the organization. The report will also include possible controls or other methods to reduce the risk to the lowest possible level. The report is to include estimated costs associated with the implementation of the suggested controls and the team’s recommendations.
  1. The risk assessment team findings will be presented at the next Patient SafetyCommittee meeting and analyzed. If necessary the committee will make a recommendation to Medical Center Administration on managing the risk reduction and control implementation. Management of the risk can occur in several ways:
  • Risk Reduction: Implement controls to reduce severity or probability.
  • Transfer: Insure against the risk
  • Avoid: Stop performing the process.
  • Accept: Perform the process despite the risk

Using the Risk Assessment Matrix on the ABCProactive Risk Assessment Worksheet, the potential risk is assigned a score of 1 to 16. Scores of 1 – 4 are considered “Low Risk” and are monitored and the risk re-assessed annually. Potential risks with scores of 6 – 9 are defined as being “Medium Risk” and are addressed by establishing controls to minimize this risk. “High Risk” areas or processes receive scores from 12 – 16 points and are subject to immediate risk reductions strategies and required action.

Only the leadership of the organization can make the decision to accept any level of risk.

  1. The Patient SafetyCommittee will review the risk assessment team’s report, determine if the risk assessment is acceptable, and, if so, using Risk Assessment Tracking System (Attachment B), define:
  • The specific risk reduction strategies to be implemented;
  • An accountable individual(s) to manage the implementation of the risk reduction strategy;
  • Timeframes for the implementation of each step in the risk reduction plan; and
  • A process to monitor implementation of the risk reduction efforts.
  • Whether any interim actions are indicated to mitigate the impact of the identified risk while the risk reduction efforts are being implemented and, if so, the specific nature of these interim actions.

The Patient SafetyCommittee will also specify the frequency with which they expect reports from the responsible individual(s) on the implementation status of risk reduction efforts.

  1. The Patient SafetyCommittee will also determine a schedule for a reassessment of the identified risk to verify that risk reduction strategies were implemented and are being followed. Frequent reassessment of the area or process will also continue until necessary policies and procedures have been written, the area is in compliance with policies, procedures, and appropriate regulations, and the Patient Safety Committee is convinced that the risk level has been lowered to an acceptable level.
  1. The Patient SafetyCommittee will assess whether an area that was considered high risk in a previous year requires an annual proactive risk re-assessment or is now a low or medium risk.
  1. When a department/area or process has met the criteria to be lowered to an acceptable level of risk, it will be moved onto the schedule of the Patient Safety Rounds visits.

Should any situation(s) that constitute an imminent danger be discovered during the course of the risk assessment, they will be reported immediately to the Patient Safety Officer or designee and the appropriate department manager or designee for appropriate follow-up action to resolve the identified issue(s).

Documentation of this risk assessment process will be found in the Patient SafetyCommittee meeting minutes.

Proactive Risk Assessment Policy 1 of 6

ATTACHMENT A

ABC MEDICAL CENTER

RISK ASSESSMENT WORKSHEET

HAZARD/RISK: ______

Location of Hazard/Risk: ______

Potential Risk (Impact) if hazard is not addressed: ______

Means of Identification: ______

______

Assessment Team: ______

______

Date of Identification: ______Date of Assessment: ______

Description of Hazard: (Attach additional sheets as necessary)

ABC MEDICAL CENTER

RISK ASSESSMENT WORKSHEET

RISK ASSESSMENT MATRIX

RISK = PROBABILITY SCORE x IMPACT SCORE

Risk Element Description

/

Probability

/

Impact

/

Risk Score

(P x I)

PROBABILITY DEFINITIONS: / IMPACT DEFINITIONS:
1 / Not likely to ever occur / 1 / Minor or no injury
2 / Possibly can occur in a year / 2 / Minor injury or illness
3 / Probably will occur in a year / 3 / Severe injury/illness
4 / Very likely within one year / 4 / Loss of life

Risk Score:1 - 4Low RiskMonitor and assess annually

6 - 9Medium RiskEstablish controls to minimize risk.

12 - 16High RiskImmediate risk reductions strategies and action required

SUBJECTIVE ASSESSMENT OF RISK:

RECOMMENDED RISK REDUCTION STRATEGIES OR PROPOSED CONTROLS: (attach separate sheet as necessary)

Proactive Risk Assessment Policy 1 of 6

ATTACHMENT B

ABC MEDICAL CENTER

PROACTIVE RISK ASSESSMENT

RISK REDUCTION TRACKING SYSTEM

Status as of: 10/3/18

Nature of Proactive Risk Assessment Conducted: ______

Date Proactive Risk Assessment Conducted: ______

Risk Assessment Team Lead/Responsible Individual: ______

Proactive Risk Assessment Team Members:

______

______

______

Risk Identified / Risk Level Classification (H/M/L) / Risk Reduction Strategy / Accountable Individual / Timeframe for Completion / Current Status
of Risk Reduction Strategy Implementation / Interim Action(s) to Mitigate Risk (if Indicated)

Approvals:

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