Clinical risk management for anaesthetists

Abstract

Clinical errors are common. They occur in at least 10% of hospital admissions and result in patients suffering through injury and worry. Clinical errors prolong hospital stay, increase costs, and lead to loss of confidence in the organization. For many cases, this will result in complaints and litigation, particularly if the situation is not managed well. In the UK, there are around 900 000 incidents or near misses every year and 2000 patient deaths as a result. Causes include human error, poor organization, lack of clear patient management plans, and inadequate communication between clinical teams. Medical errors have been highlighted throughout history as a cause of harm to patients, but came to prominence in 1999 after the publication of To err is human: building a safer health system by the US Institute for Medicine. This was followed by the Department of Health’s publication An Organisation with Memory in 2000. Since then numerous systems have been developed to minimize harm to patients and improve the quality of care. The 2010 publication by the Department of Health, Equity and Excellence: Liberating the NHS, highlights the need to focus on outcomes and quality standards, not targets. The recent report by Professor Berwick (https://www.gov.uk/ government/uploads/system/uploads/attachment_ data/file/226703/Berwick_Report.pdf) and the Francis Inquiry (http://www.midstaffspublic inquiry.com/report) made numerous recommendations focusing on providing high-quality care to patients, in particular continuous learning from errors, making patient safety and quality of care a top priority, and the importance of patient and public involvement. This will require a variety of institutional and cultural changes, including a contemporary audit process with review of outcomes, engaging staff in the complaints process, and also a high standard of professional training. All these are integral to risk management (https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/ 226703/Berwick_Report.pdf, http://www.midstaffs publicinquiry.com/report). A clinical error can be defined as a clinical incident that has deviated from the intended treatment, intervention, or diagnostic plan, which may or may not result in an untoward outcome (http://www.clinical-governance-toolbox.com/ risk-management). Clinical risk is the potential for the error to occur and this requires both an active error and contemporaneous conditions that allow it to occur. Although risks are impossible to eliminate completely, they can be reduced by minimizing error and improving latent conditions (e.g. equipment). Clinical risk management (CRM) provides a multidisciplinary team system to identify, record, analyse, and monitor clinical incidents, and reduce harm to patients. Although serious incidents are rare in anaesthesia and the theatre environment, both areas have a relatively high risk of clinical errors. A recent Quality and Safety update by the Royal College of Anaesthetists reported 4057 anaesthesia-related incidents over 3 months, of which 68.5% were near misses and 7.9% resulted in moderate-to-severe harm or death (http://www. rcoa.ac.uk/document-store/patient-safety-updateoctober-december-2012). CRM therefore forms a key aspect for anaesthetists in improving patient safety and quality of care. Risk management is the systematic process by which NHS boards are responsible for the management and monitoring of risk within their organization. These range from corporate to personal risk. Risk management is covered by a wide range of legislation and is a key component of Clinical Governance. The process aims to identify risk and to reduce incidence of injury, faults, errors, accidents, and improve overall quality of patient care (http://www.clinical-governance-toolbox.com/ risk-management, http://www.clinicalgovernance. scot.nhs.uk/section3/riskmanaged.asp). This article will review CRM in anaesthesia. The definitions have been described in a previous article published in this journal and will not be covered here. Key points Clinical errors are common. Anaesthetists work in environments where the potential for serious harm is high. Clinical risk management is a systematic process for reducing and managing harm to patients.