1) I wasn’t really sure what Risk Management meant. I know I’ve
heard of it before though.
2) After this unit’s learning, I realized how important Risk
Management is. There is a saying that says, “To be human is to error.” To apply
this to the patient-care setting, most all nurses render care with their best
intentions in mind, but even with these good intents, errors still occur. Risk Management realizes that nurses cannot
predict the future and what will happen with a patient. It is never the
intention of the nurse to cause injury, neglect or harm the patient. This being
said, Risk Management is in operation to ensure better safety measures are
implemented in order to keep patients safe and protect staff members.
Risk Managers look at domains and areas of risk. These
include: finance, operational/clinical, human capital, legal/regulatory,
technology, and natural disasters/hazards. For example, for financial risks, liability
insurance is bought to cover the company’s risks. For human capital risks, research
can be done to gather data on what part of the shift nurses tend to make the
most mistakes. This way appropriate interventions
can be made to limit or prevent the risks from occurring (i.e. Risk Mitigation).
An important role hospital staff can play is filling out “Incident
Reports” to help track and view trends of various events, complaints, grievances,
serious safety issues, or sentinel events. It is important to document only the facts of
the event, remembering the Who, What, When, and Where information. Because
Incidents Reports are protected pieces of information, a nurse must never refer
to it in her nursing notes. If the nurse does, it can be “discovered” by the
court during depositions and cases.
When an event occurs, it is necessary to ask the initial question,
“What is the standard of care?” Then, risk management will research to see if
what actually happened was a breach in the standard of care, and if that breach
caused the patient injury or damage.
Risk management is so important because it aims at getting
serious safety events down to zero. Across the U.S. medication errors, falls,
and patient care/treatment are high volume nursing event types. If we all can
decrease injuries and errors by 40%, 60,000 patient lives can be saved.
3) I enjoyed the discussion about the 27-year old
intoxicated and aggressive patient getting serious burns on his body, and how
the nurse leader would go about resolving the event. It was interesting to see
my team member’s ideas on how to fix the problem in the future. I had forgotten
that a 1:1 psych sitter could have immediately helped prevent the burns from
occurring, due to rapidly putting out the fire and noticing the patient
movement. As an ER nurse myself, this type of patient is quite common, and it
was eye-opening to see the results of what could happen if I were not diligent.
The scholarly article I looked up on the topic ‘Risk Management in
Nursing Leadership’ was interesting. Failure Mode Effects Analysis (FMEA) is a
systematic method, developed by the U.S. military, for evaluating parts of
processes in need of change (Reams, 2011). Nurse leaders can use this method to
make the delivery of healthcare safer for patients. It is an 8-step process which
allows for thoroughness and questioning what may not be right. The first step involves
identifying a system and a process within it that’s likely to cause harm to a
patient. A multi-disciplinary team will
break the process a part and analyze each part of it using a flow chart.
Problems that need fixing will be identified and assigned a severity score (how
mild-catastrophic the patient outcome will be) and probability score
(likelihood of error occurring). These scores will be multiplied together and then
ranked in order. A score of 16 would be considered a severe threat to patients,
whereas a score of 6 would not be as big a concern. Items with a higher score
would be given higher priority to address and fix the process. FMEA is a straightforward
process that can decrease and stop harmful incidents from occurring if
conducted appropriately by the nurse manager and multidisciplinary team (Reams,
2011).
4) I plan to always be honest and forthright with my
patients. I will continue to document Incident Reports if they occur. I realize
involving Risk Management is helpful in preventing errors to patients in the
future. We are all human—unintended mistakes happen.
5) I enjoyed this unit. It really struck me how important
the role of Risk Management is in limiting risks. I realize how important all
the skills certifications are (i.e. applying restraints, etc) now. It ensures
competency while also limits potential risks to patients.
Reference
Reams, J. (2011 May). Making FMEA work for you. Nursing Management, 18-20. doi: 10.1097/01.NUMA.0000396500.05462.6e
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