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Promoting patient safety through prospective risk identification: example from peri-operative care
1Department of Anaesthesia, Royal Lancaster Infirmary, Ashton Road, Lancaster, UK. andrew.f.smith@mbht.nhs.uk
Quality & Safety in Health Care
|February 23, 2010
Summary
This study applied a prospective risk analysis technique to identify 102 non-operative risks in elective surgery. Key recommendations focused on staffing, equipment, and pre-operative patient assessment to enhance patient safety.
Area of Science:
- Healthcare Management
- Patient Safety
- Risk Analysis
Background:
- Patient safety incident investigation traditionally relies on retrospective analysis.
- Prospective risk analysis methods are underutilized in healthcare settings.
Purpose of the Study:
- To implement and evaluate a prospective risk identification technique for non-operative risks in adult elective surgery.
- To develop and prioritize actionable recommendations for risk mitigation.
Main Methods:
- Utilized a customized "what if" checklist and risk matrix for prospective risk identification.
- Involved 20 healthcare staff and risk experts convened by the UK National Patient Safety Agency.
- Prioritized recommendations based on cost, ease, and speed of implementation.
Main Results:
- Identified 102 risks and generated 95 recommendations.
- Top 20 recommendations addressed approximately 75% of estimated risks.
- Major risk areas included staffing/organization (21%), devices/equipment (19%), and pre-assessment (12%).
Conclusions:
- The prospective risk identification technique is feasible for healthcare staff with expert facilitation.
- This approach offers comprehensive risk reduction potential beyond single-issue alerts.
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