Risk management: beyond analysis methods

Published on -

 
 
Risk management is based, in part, on analysis of declarative elements which must lead to the implementation of improvement or prevention measures. The multiple origin of the contributing factors makes the analysis complex and requires to be structured in order to be effective. Digital technology become therefore a valuable aid.

Different methods allow to investigate the contributing factors (human, material, organizational, structural ...), to analyze the preliminary causes essential to the search for adapted answers. Depending on a priori and a posteriori risks, the methods of analysis will be different.

 

The best known methods are the FMEA (Failure Mode Effects Analysis), the root-cause analysis, EXperience Return Committee (CREX in French), + Orion / ALARM. These analysis methods identify malfunctions and mitigate these risks through the implementation of corrective solutions.

 
             The digitization of risk analysis methods becomes a real challenge.
 

Beyond these methods, relying on digital solutions for risk analysis is an issue in organizations. They have the advantage of structuring the search of contributing and latent factors, of the root causes of the occurrence.

This multidisciplinary approach allows, apart from any guilty approach to understand the chain of circumstances, situations and acts that have led to the expression of a risk which is the triggering factor of these analyzes.


 

Concrete example: Risk analysis in the hospital sector

 

Following a septic shock, a patient was taken in charge in surgery. This event necessitated a thorough analysis of the occurrence conditions. Whatever the method used, each dimension of the management is chronologically analyzed, associating all the factors that may have led to this infection.

 

Among these facts: organization, practices, team, logistics, but also the patient. Originally from Central Europe, the patient did not speak French. The barrier of the language did not facilitate exchange and understanding. Therefore the follow-up of the recommendations led her to take a shower without occlusive dressing (following a change of dressing set). This action resulted in a wound infection.

 

In this example, the nurse by noticing the wound degradation affecting the general condition of the patient has, of course, started by alerting the doctor of the department and then disclosing the adverse event. This reporting was automatically transmitted, as soon as validation, to the quality department and the referent in charge of the infectious risks prevention.

 

The "Risk Management" unit of the health facility characterizing the event as serious, decided to set up a root cause analysis using the ALARM method, the method in force at the institution.

 

              Through the adverse event reporting tool, the quality referrer triggered a                       meeting by inviting the engaged professionals or functions to participate.

 
 

Digitizing adverse event reporting process and workflows generated specific alerts. After a chronological search of the facts, all the factors were analyzed.

In order to avoid  a replication of this adverse event in the future, improvement measures have been recommended:

 
  • For the reception for a search for resources likely to promote the exchange with the patient or his entourage ...
  • At the pharmacy on the sampling conditions during the procurements which would have made it possible to highlight the absence of occlusive dressing in the sets made available to the services or to alert on the need to acquire these medical devices ...
  • Towards the care service in the execution of the act, the information transmitted to the patient and control of his understanding ...
  • At the maintenance department in the controls of filter changes on showers and faucets ...
  • To the organization to reinforce the responsiveness to an event of this order …

Digital for more responsiveness

 

To be able to link all of this information (event, action, risk, process of adverse event treatment) and whatever the request, be able to consolidate all these elements to follow the answers. These are the advantages of a reactivity that only digitization allows to optimize.

Following the ALARM analysis, processes of patients care, control and maintenance were redefined. Personnel awareness of the risk factors related to care of the patient and those around him was also made.

  • How can we identify all the parameters likely to affect the observation of an event?
  • How to list the risk of occurrence without having available all the data allowing this analysis?
  • Were the different circumstances avoided? Probably…! How to ensure follow-up of good practices, recommendations ...?

It is the diversity of these factors, characteristic of the risks that we must map. Digital technology allows to classify before allowing the control by the different actors.

 

For further :

> Digitize your risk analysis methods with BlueKanGo Health

> Download the guide "The new orientation of Quality and Risk Management"

Photo credit: BlueKanGo
Nouveau call-to-action