Managing the Risk of Adverse Events Using the Example of a Hospital in Wroclaw

Abstract. Health Care Centres are institutions which, because of their specificity and character, are particularly exposed to various kinds of risk. One of the most important and most frequently used methods of risk management is the black spots method. The research material collected for the study comes from one of the hospitals in Wrocław. All hospital stays of the C22 (Face and Jaw Surgery Ward) and H05 (Injury and Orthopaedics Surgery Ward) settlement groups (DRG) were analysed - a total of 178 hospitalisations. The black spots method was used in the study, which consisted of risk identification, the ordering of threats and proposals for remedial actions. Using the black spots method, it was possible to identify adverse events that occurred during the hospitalisation of patients with H05 and C22 DRGs in the Injury and Orthopaedics Surgery Ward and Facial and Jaw Surgery Ward. In both cases, the treatment costs for patients with complications were higher than for the stays without complications.

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Presumed adverse events in health care are a frequent indication for medico-legal autopsy in Finland

Forensic Science Medicine and Pathology ◽

10.1007/s12024-019-00193-4 ◽

2019 ◽

Vol 16 (1) ◽

pp. 65-70

Author(s):

Lasse Pakanen ◽

Noora Keinänen ◽

Paula Kuvaja

Keyword(s):

Health Care ◽

Risk Management ◽

Adverse Event ◽

Adverse Events ◽

Gastrointestinal Surgery ◽

Legal Protection ◽

Clinical Risk Management ◽

Data Set ◽

Manner Of Death ◽

Clinical Risk

AbstractThe medico-legal autopsy is an essential tool in investigating deaths caused by an adverse event in health care, for both clinical risk management and for professional liability issues. However, there are no statistics available regarding the frequency of autopsies performed due to suspected adverse events. This study aimed to determine the number of medico-legal autopsies done because of presumed adverse events, whether these events were unintentional, medical errors or cases in which malpractice was suspected. Furthermore, differences in treatment types, causes and manner of death were analyzed. The data was obtained from all medico-legal autopsies performed in Northern Finland and Lapland during 2014–2015 (n = 2027). Adverse events were suspected in 181 (8.9%) cases. The suspicions of an adverse event occurring were most often related to medication, gastrointestinal surgery and orthopedic surgery. The manner of death was classified as medical (or surgical) treatment or investigative procedure in 22 (12.2%) cases. The causes of death were completely unrelated to the suspected adverse event in 41 (22.7%) cases. In conclusion, the frequency of presumed adverse events was quite high in this data set, but in the majority of the cases, the suspicion of an adverse event causing death was disproved by an autopsy. Nonetheless, proper investigation of these cases is essential to ensure legal protection of the deceased, next of kin and health care personnel, as well as to support clinical risk management.

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Implementation of a sustainable enterprise risk management framework: The Administrator on Duty model

Journal of Hospital Administration ◽

10.5430/jha.v5n2p80 ◽

2016 ◽

Vol 5 (2) ◽

pp. 80

Author(s):

Linda L Vila ◽

Vito Buccellato

Keyword(s):

Health Care ◽

Risk Management ◽

Organizational Performance ◽

Health Care Organization ◽

Well Being ◽

Safety Net ◽

Risk Identification ◽

Enterprise Risk Management ◽

Care Organization ◽

Enterprise Risk

Background: Today’s health care landscape requires a new standard of service delivery aimed at quality outcomes, cost-effective provisions of coordinated treatment, and access to equitable care. This standard has brought emerging risks that pose threats to the operational and financial well-being of health care organizations, especially safety net hospitals. The establishment of enterprise risk management (ERM) programs guided by the efforts of efficacious health care managers will promote deeper risk analysis, engagement of the entire health care organization, and structured, coordinated and cohesive mitigation responses to risk exposures.Objective: To establish and implement an ERM program using the Administrator on Duty (AOD) model that will promote a patient-centric paradigm of care while optimizing organizational performance and mitigating risk and exposure.Results: The AOD model significantly contributes to all phases of ERM, particularly risk identification, risk assessment, risk response and monitoring. The model, as perceived by both AODs and hospital senior leadership, provides tremendous benefits to a health care organization. These include, among many others, a substantial leadership presence, dynamic risk mitigation efforts, continuous education to staff and facilitation of problem solving and conflict resolution.Conclusions: The AOD program is a vital constituent of an ERM endeavor. AODs are pivotal to managing the global risk terrain of a health care organization and play a substantial role in promoting patient, staff and visitor safety while working to ensure potential and actual risk issues are addressed timely and appropriately.

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The Activities of Risk Management

Urologia Journal ◽

10.1177/039156030907600303 ◽

2009 ◽

Vol 76 (3) ◽

pp. 185-191

Author(s):

G. Marino ◽

O.G. Di Primio ◽

F.C. Cortese ◽

M. Pedalino ◽

R. Vella ◽

...

Keyword(s):

Health Care ◽

Risk Management ◽

Adverse Events ◽

Health Workers ◽

National Level ◽

Common Denominator ◽

Urological Procedures ◽

Successful Approach

Introduction The activities of Risk Management at a department of urology involve specialist health workers, technical and administrative staff as the common denominator is communication, simplification of processes and the quality of health care provision. The Authors present their experience on the management of risk in urology and an attempted classification of adverse events with possible dysfunction in the clinical management in urology department. Materials and Methods Our analysis included those adverse events that occurred from January to December 2008. A total of 18 adverse events were identified from 638 urological procedures divided according to diagnosis, treatment and type of hospitalization. Results The following events were assessed: number of cases with wound infection: 5 (4.7%), diastasis of the surgical wound: 3 (0.47%), catheter obstructions that required therapeutic endoscopic or surgical haemostatic procedures: 5 (0.78%), delayed administration of treatment: 3 (0.47%) and accidental fall out of bed: 2 (0.31%). Conclusions The transition from a reactive to a preventive system remains the key to provide the citizen with the best health care in safety conditions. The involvement of different organizational and managerial levels in an optimal atmosphere in the absence of stress appears to be the most balanced and successful approach, especially putting aside the attitude of assigning error culpability. The transmission of individual experiences at a regional and national level will allow refining the project, which foresees the identification and classification of possible events and especially the ways and preventive procedures to achieve them.

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Systems for Risk Identification as a Stage of Healthcare Risk Management

Journal of Health Development ◽

10.32921/2225-9929-2021-1-41-31-38 ◽

2021 ◽

Vol 1 (41) ◽

pp. 31-38

Author(s):

Gaukhar Alzhaxina ◽

◽

Gulnar Kurenkeyeva ◽

Keyword(s):

Health Care ◽

Risk Management ◽

Patient Safety ◽

Environmental Changes ◽

Risk Identification ◽

Incident Report ◽

Healthcare Organizations ◽

Safety Incident ◽

Patient Safety Incident ◽

System Risk

The relevance of studying the issues of risk management is also associated with environmental changes, both external and internal. In connection with the COVID-19 pandemic, healthcare organizations faced new risks related to the safety of patients and staff, the activities of the healthcare organization itself in the context of the spread of a global, previously unknown infection. The article discusses approaches to methods of identifying risks associated with medical activities in the system of Kazakhstan and foreign healthcare. Keywords: Health care system, Risk Management, Patient Safety, Incident, Incident report

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A Probabilistic Method for Computing Quantitative Risk Indexes from Medical Injuries Compensation Claims

Methods of Information in Medicine ◽

10.3414/me12-01-0074 ◽

2013 ◽

Vol 52 (05) ◽

pp. 374-381

Author(s):

S. Dalle Carbonare ◽

F. Folli ◽

E. Patrini ◽

P. Giudici ◽

R. Bellazzi

Keyword(s):

Health Care ◽

Risk Management ◽

Adverse Events ◽

Health Care Services ◽

Care Delivery ◽

Probabilistic Method ◽

Parametric Modeling ◽

Risk Level ◽

Loss Distribution ◽

Compensation Claims

SummaryBackground: The increasing demand of health care services and the complexity of health care delivery require Health Care Organizations (HCOs) to approach clinical risk management through proper methods and tools. An important aspect of risk management is to exploit the analysis of medical injuries compensation claims in order to reduce adverse events and, at the same time, to optimize the costs of health insurance policies.Objectives: This work provides a probabilistic method to estimate the risk level of a HCO by computing quantitative risk indexes from medical injury compensation claims.Methods: Our method is based on the estimate of a loss probability distribution from compensation claims data through para -metric and non-parametric modeling and Monte Carlo simulations. The loss distribution can be estimated both on the whole dataset and, thanks to the application of a Bayesian hierarchical model, on stratified data. The approach allows to quantitatively assessing the risk structure of the HCO by analyzing the loss distribution and deriving its expected value and percentiles.Results: We applied the proposed method to 206 cases of injuries with compensation requests collected from 1999 to the first se -mester of 2007 by the HCO of Lodi, in the Northern part of Italy. We computed the risk indexes taking into account the different clinical departments and the different hospitals involved.Conclusions: The approach proved to be useful to understand the HCO risk structure in terms of frequency, severity, expected and unexpected loss related to adverse events.

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Adverse Events and Malpractice Claims in Endodontics

International Journal of Medical and Surgical Sciences ◽

10.32457/ijmss.2015.002 ◽

2018 ◽

Vol 2 (1) ◽

pp. 367-375

Author(s):

Gabriel Fonseca ◽

Karina Mira ◽

Héctor Beltrán ◽

Katherine Peña ◽

Violeta Yendreka

Keyword(s):

Health Care ◽

Risk Management ◽

Adverse Event ◽

Adverse Events ◽

Inappropriate Drug ◽

Negative Effects ◽

Significant Frequency ◽

Iatrogenic Complications ◽

Malpractice Claims ◽

Health Care Treatment

An "adverse event" has defined as a non-intentional complication result of health care treatment, and although it can have different causes, always involves the providing care, but not the complications inherent to the patient’s disease itself. Adverse events, iatrogenic complications and malpractice have been clearly differentiated because only malpractice causes liability: while iatrogenic events can be result of a well-performed procedure, malpractice involves damage caused by negligence or lack of knowledge, and it is a potential for complaint and liability claim. In dentistry, endodontics is one of the specialties of greatest challenge where adverse events and malpractice claims have been reported with significant frequency. We present a literature review searching the main causes and results of malpractice claims in endodontics. Three articles from Italy, Israel and Denmark were selected, where the most claimed adverse events were root perforations, inappropriate drug therapies, defective root fillings and instrument fracture. One of the articles referred to malpractice verdicts in 97.5 % of claims. Since endodontics leads dental malpractice claims in Chile, strategies of risk management for these procedures are discussed; the adherence to strict protocols is proposed and measures to minimize the negative effects of these events are recommended.

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