Skip to main content
  • 3172 Accesses

Abstract

Doctors are highly skilled at managing patients’ clinical risks and consider these as part of everyday care. Many have also participated in clinical quality improvement processes, again aimed at reducing clinical risk. Yet when it comes to system level risk management, involvement by medical practitioners is much lower, and valuable insights can be missed. This chapter provides a practical example of a significant clinical risk in contemporary medicine and shows how formal risk management approaches can assist in reducing the risk of undetected patient deterioration due to alarm fatigue. It guides the reader through the core elements of risk management as described in the Australiana and New Zealand Standard, highlighting the importance of considering the context, through to identifying, applying and monitoring appropriate solutions.

A ship in harbor is safe, but that is not what ships are built for From Salt from My Attic

—by JA Shedd

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Wilson R, Runciman W, Gibberd R et al (1995) The quality in Australian health care study. Med J Aust 163:458–471

    CAS  PubMed  Google Scholar 

  2. IOM (1999) To err is human: building a safer health system. Institute of Medicine, Washington

    Google Scholar 

  3. Amalberti R, Auroy Y, Berwick D, Barach P (2005) Five system barriers to achieving ultrasafe health care. Ann Intern Med 142:756–764

    Article  PubMed  Google Scholar 

  4. Etchells E, Koo M, Daneman N et al (2012) Comparative economic analyses of patient safety improvement strategies in acute care: a systematic review. BMJ Qual Saf 21(6):448–456

    Article  PubMed  Google Scholar 

  5. StandardsAustralia (2009) AS NZS ISO 3100-2009 risk management principles and guidelines. SAI International

    Google Scholar 

  6. Vincent C (2007) Editorial—incident reporting and patient safety. BMJ 334:51

    Article  PubMed Central  PubMed  Google Scholar 

  7. Amalberti R, Hourlier S (2011) Human error reduction strategies in health care. In: Carayon P (ed) Handbook of human factors and ergonomics in health care and patient safety. CRC Press, US

    Google Scholar 

  8. Amalberti R (2006) Optimum system safety and optimum system resilience: agonist or antagonists concepts? In: Hollnagel E, Woods D, Levison N (eds) Resilience engineering: concepts and precepts. Ashgate, Avebury, pp 238–256

    Google Scholar 

  9. Williams JC (1988) A data-based method for assessing and reducing human error to improve operational performance. IEE Fourth Conference on Human Factors in Power Plants, Monterey, 6–9 June 1988

    Google Scholar 

  10. StandardsAustralia (2009) AS/NZS ISO 31000:2009 Risk management—principles and guidelines. SAI Global

    Google Scholar 

  11. Mead M. “Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.” 1901–1978

    Google Scholar 

  12. Norman D (1988) The design of everyday things. Basic Books, New York

    Google Scholar 

  13. Reason J (2008) The human contribution. Ashgate, Surrey

    Google Scholar 

  14. Reason J (1997) Managing the risks of organizational accidents. Ashgate, Surrey

    Google Scholar 

  15. Rasmussen J (1982) Human errors: a taxonomy for describing human malfunction in industrial installations. J Occup Accid 4:311–333

    Article  Google Scholar 

  16. Ergonomics SfHFa (2013) Human factors definitions. http://www.hfes.org/Web/EducationalResources/HFEdefinitionsmain. html. Accessed Mar 2012

  17. Grote G (2012) Safety management in different high-risk domains—all the same? Saf Sci 50:1983–1992

    Article  Google Scholar 

  18. Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Staionary Office, London

    Google Scholar 

  19. Knox R (2014) Silencing many hospital alarms leads to better health care. Health news from NPR

    Google Scholar 

  20. Bell L (2010) Monitor alarm fatigue. Am J Crit Care 19:38

    Article  PubMed  Google Scholar 

  21. Hannibal G (2011) Monitor alarms and alarm fatigue. AACN Adv Crit Care 22(4):418–420

    Article  PubMed  Google Scholar 

  22. Sendelbach S (2012) Alarm fatigue. Nurs Clin North Am 47:375–382

    Article  PubMed  Google Scholar 

  23. Bell L (2010) Monitor alarm fatigue. Am J Crit Care 19(1):38

    Article  PubMed  Google Scholar 

  24. Mitka M (2013) Joint commission warns of alarm fatigue. JAMA 309:2315

    Article  CAS  PubMed  Google Scholar 

  25. Edgworthy J (2012) Medical audible alarms: a review. J Am Med Inform Assoc 20:584–589

    Article  Google Scholar 

  26. ECRIInsitute (2013) Top ten health technology hazards. ECRI, 2012 November 2012. Report for 2013

    Google Scholar 

  27. ECRIInstitute (2007) The hazards of alarm overload. URL: www.ecri.org/Products/Pages/Hazards ofAlarmOverload.aspx. Accessed 9 Jan 2014

  28. TheJointCommission (2013) Sentinel event alert: medical device alarm safety in hospitals

    Google Scholar 

  29. IHI (2013) The leader’s role in medical device safety. Reprinted from Healthcare Executive May/June 2013

    Google Scholar 

  30. Westbrook J (2010) The impact of interruptions on clinical task completion. Qual Saf Health Care 19(4):284–289

    Article  PubMed  Google Scholar 

  31. Dixon-Woods M, Amalberti R, Goodman S, Bergman B, Glasziou P (2011) Problems and promises of innovation: why healthcare needs to rethink its love/hate relationship with the new. BMJ Qual Saf 20:i47–i51

    Article  PubMed Central  PubMed  Google Scholar 

  32. CEC (2010) Between the flags program: keeping patients safe. http://www.cec.health.nsw.gov.au/programs/between-the-flags. Accessed 3 Jan 2014

  33. NSWHealth (2013) PD2013_049 recognition and management of patients who are clinically deteriorating (replaces PD 2011_077) (CEC (ed)). NSW Health, Sydney

    Google Scholar 

  34. ASCQHC (2011) National safety and quality health service standards. Australian Commission on Safety and Quality in Health Care, Sydney

    Google Scholar 

  35. NSWHealth (2009) Risk management—enterprise-wide policy and framework—NSW health (Management CGaR (ed)). NSWHealth, Sydney

    Google Scholar 

  36. TheJointCommission. The Joint Commission Perspectives. The Joint Commission announces 2014 patient safety goal2013

    Google Scholar 

  37. Singh H, Giardina TD, Petersen LA, Smith MW, Paul LW, Dismukes K et al (2012) Exploring situational awareness in diagnostic errors in primary care. BMJ Qual Saf 21:30–38

    Article  PubMed Central  PubMed  Google Scholar 

  38. Pysyk C, Davies J (2013) Using the surgical safety checklist. Acta Anaesthesiol Scand 57:135–137

    Article  CAS  PubMed  Google Scholar 

  39. Reinertsen J (2010) Institute for healthcare improvement: rounding to influence. Healthc Exec 25(5):72–75

    PubMed  Google Scholar 

  40. Vincent J (2005) Give your patient a fast hug (at least) once a day. Crit Care Med 33:1225–1230

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Bronwyn Shumack .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Shumack, B. (2015). Risk Management. In: Patole, S. (eds) Management and Leadership – A Guide for Clinical Professionals. Springer, Cham. https://doi.org/10.1007/978-3-319-11526-9_7

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-11526-9_7

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-11525-2

  • Online ISBN: 978-3-319-11526-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics