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On 27th May
2002, Dr
Andrew Reid (Clinical
Risk Manager & Solicitor) at Northwick Park Hospital came to
speak to the TVCS about Clinical Risk Management (CRM). Many thanks
to him for lending me his presentation notes. The topics of discussion
included basic principles of clinical risk management; comparison
with other industries; and the application of CRM to Cytology.
Risk is essentially a number - what are the chances of a bad
thing happening?
The basic principles of clinical risk management entail identifying,
analysing, then eliminating or minimising risk. The latter involves
accepting and preparing to deal with the consequences of running
risk. Examples include train crashes; aviation accidents; adverse
healthcare events.
Risk analysis asks when, where and how does the risk arise and who
does the risk involve.
Which
would you prefer - a 60% chance of cure - or a 40% chance of effect?
Rocket Science
On a 'frosty' 28 January 1986, the Space Shuttle Challenger was
launched and disintegrated seconds after launch, killing all seven
crew members. There had been a blow out on one of the primary booster
O-rings. The Presidential Commission report identified that there
was a serious flaw in decision making prior to launch - when known
problems concerning the O-ring seals included a recommendation against
launch at temperatures below 53 degrees Fahrenheit.
"Commissioner Feynman observed, the decision making process
was 'a kind of Russian roulette...(The Shuttle) flies (with o-ring
erosion) and nothing happens. Then it is suggested, therefore, that
the risk is no longer so high for the next flights. We can lower
our standards a little bit because we got away with it last time.
...You got away with it, but it shouldn't be done over and over
again like that."
Latent Failures
Latent failures are the accidents waiting to happen - the small,
otherwise innocuous faults that exist in complex systems. Latent
failures in Cytology include sampling errors, processing errors,
artefacts, managing large volumes of work. These and other human
errors result from organisational factors which create pre-existing
accident causes. The Space Shuttle Challenger accident reinforces
the view that the latent failures would have been minimised if an
appropriate safety culture had been in place.
Active errors
Active errors involve taking deliberate risks; violating rules (deviation
from protocols); taking shortcuts, e.g. The Herald of Free Enterprise.
Active errors in Cytology include wrong technique in sampling; wrong
processing; detection failures, and misconceptions of interpretation.
Most disasters are a combination of latent and active errors. The
active errors in the Kent and Canterbury disaster involved both
a breach of protocols and misinterpretations. The latent failures
involved errors in the fail-safe protocol. There were also system
errors - failures in liaison between GPs, the Health Authority,
and the laboratories.
System Failures
System failures are a combination of both latent and active errors,
and other factors such as patient and organisational factors. System
failures feature hindsight 'cascades' where errors can be identified
like dominoes toppling over. Rarely are individuals solely to blame,
although they often appear to take the blame - usually because they
feature last in a sequence.
Risk Perception
The public perception of risk also poses notoriously difficult challenges
to risk communicators. Would you prefer a 60% chance of cure or
a 40% risk of side effect? If you suffer the side effect the 'risk',
in terms of individual fate, is 100%. Everyone has a certain risk
of developing cancer. Risk involves factors that can be modified
through changes to the environment (like having a smoke-free workplace
and home) or through lifestyle decisions (like smoking, diet and
exercise) and factors that can't be changed (like age and family
history).
Risk Reduction
Risk reduction is taking action to reduce or 'cut down' your individual
risk of developing cancer. Risk can be increased or decreased significantly
by the lifestyle choices you make (like engaging with health screening
programmes) or the kind of environment you live and work in. But
even so a person at low risk may get cancer, just as a person at
high risk may not.
The incidence of cervical cancer has dropped by 40% since the NHSCSP
was established. Even so, the burden of suffering in 1997 was approximately
2,740 new cases of cervical cancer, almost half of whom had never
had a smear test. The biggest risk factor is therefore still non-attendance.
Cervical screening is beset with system failures, and complete reduction
(elimination) is not an option. Maximum reduction (minimisation)
has a coherent and flexible objective. It admits the presence of
some residual risk. Optimum reduction is achieved in regulations
- monitoring and addressing known inherent risks.
To conclude, few things in Healthcare screening or diagnosis are
risk free. Government policy works out what is a reasonable amount
to spend to avert harm. It targets sensitivity and specificity,
assesses risks, analyses the 'costs' of running risks, monitors
feedback, performs root cause analysis of adverse events, and so
seeks to further reduce risks and maximise benefits.
At the next adverse event in cytology screening - when you hear
that quality assurance in cervical screening is not rocket science
- Dr Reid has showed us how 'system failures' offer food for a useful
comparison.
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