Evolution of healthcare risk management
| Then | Now |
|---|---|
| • Number one goal: to protect the hospital's financial resources and reputation | • Number one goal: to improve patient safety; minimize risk of harm to patient through better understanding of systemic factors that inhibit caregiver's ability to provide safe care |
| • Paper occurrence form required | • Variety of methods to report: paper form, electronic form, telephone call, anonymous reporting, person to person reporting |
| • Investigate only the serious occurrences | • Encourage reporting of “near misses” and investigate and discuss the potential |
| • Interview staff one on one when there is an adverse incident | • Have root cause analysis meetings with the entire team of caregivers |
| • Information from investigation kept confidential | • Develop corrective action, share with Patient Safety Committee and others within the organization |
| • Blame and train | • Perform a criticality analysis chart and determine the root cause of the “near miss” or the adverse occurrence |
| • Talk to the patient/patient's family only if necessary and be vague about findings | • Advise physician to speak directly with the patient/family and talk with them about any unexpected outcome and error; keep them appraised of steps taken to make environment safe for next patient |
| • Work with department involved to develop corrective action | • Work with the team to develop a patient safety improvement plan |
| • Assume that action is taken to correct the problem that occurred, notice only when it happens again that no action is taken | • Monitor the patient safety improvement plan to determine that changes have been initiated and that the changes have made a difference |
| • Keep patients in the dark about risk management and occurrence reporting | • Establish ongoing patient safety education, publish patient safety bulletins that address specific patient safety issues and the organization's approach to managing them. Provide opportunity for patients to identify methods of improving patient safety and to share them with administration |