Risk management is a process by which adverse outcomes are minimised by analysing their causes and instituting preventive steps, thus reducing both the chance of an adverse event occurring and its cost (both clinical and financial), should it occur. Although it may involve audit or quality improvement projects, the emphasis is more on the analysis of individual real or potential adverse events rather than assessment of standards of practice generally. This approach is widely used throughout (and outside) health care to reduce risk and also liability.
Problems and special considerations
Traditionally, anaesthetic risk has been seen as individual-based (e.g. arising from human error), but recent emphasis has focused on risk being operating-room-based (arising from the interaction between anaesthetists and their working environment, in this case labour ward), and most recently system-based (human actions superimposed on inherent flaws in a system or process).
Examples of system-based errors might be seen in the case of a patient with preeclampsia who presents unbooked late in pregnancy, requires emergency caesarean section but is not given antacid prophylaxis because her drug chart is missing, and is then anaesthetised by a junior trainee, aspirates on induction and is transferred to another hospital because of a shortage of intensive care beds.
Management options
Important steps in the development of a risk-management programme include:
• Analysis of risks (e.g. morbidity and mortality meetings, critical incident reporting schemes)
• Prevention of risks associated with routine activities (e.g. proper training and supervision, provision of trained anaesthetic assistants)
• Avoidance of particularly high-risk practices (e.g. general anaesthesia for caesarean section)
• Minimising the severity of adverse events should they occur (e.g. having an antacid prophylaxis protocol in place)
• Risk financing (e.g. indemnity)
• Having a system in place for dealing with disasters and complaints: this may reduce both psychological sequelae and legal proceedings
Such a programme has implications for training, purchase and upkeep of equipment and other potentially costly processes but should ultimately reduce costs related to legal actions.
Relatively simple measures can be taken to reduce the risks attached to specific activities, such as analysing a single procedure (e.g. caesarean section) at all its stages or focusing on a specific complication (e.g. dural tap) and working back. A climate in which mistakes and critical incidents can be openly discussed without fear of retribution is important. More formal analytical techniques (e.g. root cause analysis) can be used to reveal underlying weaknesses in systems; such methods may have a role in helping to predict incidents but are usually employed to analyse incidents once they happen.
Once a risk-management programme is instituted, specific audits can then be performed to highlight areas where inadequacies still exist. Protocols are generally seen as a way of reducing risk if they are widely circulated and followed (itself a worthy subject of audit). Wider use of critical incident reporting schemes has been suggested as a more effective means of improving service than traditional reliance on outcome studies (e.g. looking at mortality), firstly because serious adverse outcomes are rare, and secondly because a proactive approach is inherently more attractive than a reactive one.
The organisation that handles claims against NHS bodies is called NHS Resolution (previously the NHS Litigation Authority; see Chapter 170, Medicolegal issues). Through its Clinical Negligence Scheme for Trusts (CNST), NHS bodies are encouraged to improve their structure and processes through financial incentives. The costs of the scheme are met by the bodies themselves according to whether they meet required CNST standards of organisational structure, routine and high-risk clinical care, and communication. Trusts may meet none (level 0), some (levels 1 or 2) or all (level 3) standards, and their contributions are adjusted accordingly.
Key points
• Risk may involve human actions and/or an underlying flawed system.
• Management includes:
- Analysis
- Reduction of risk attached to routine activities
- Avoidance of high-risk activities
- Damage limitation
- Risk financing
Further reading
Boothman RC, Blackwell AC. Integrating risk management activities into a patient safety program. Clin Obstet Gynecol 2010; 53: 576-85.
Pettker CM. Systematic approaches to adverse events in obstetrics, Part I. Event identification and classification. Semin Perinatol 2017; 41: 151-5.
Pettker CM. Systematic approaches to adverse events in obstetrics, Part II. Event analysis and response. Semin Perinatol 2017; 41: 156-60.
Smith R. Clinical risk management in obstetric practice. Obstet Gynecol Reprod Med 2017; 27: 277-84.