Risk management in healthcare is potentially more important than in any other industry. Many researchers, including Moskowitz (2018), are now suggesting that there is a clear link between implementing a successful risk management strategy and the education of all employees.
So, is it time for an overhaul of risk management education?
One answer to this is offered by Kuhn and Youngberg (2002) who suggest that it’s perhaps time for the traditional risk management model to evolve and become more responsive to the increasing demands for safety. They ask the following three pertinent questions:
- How can it be that the problems identified by risk managers over the years have not yet been solved?
- What is it about the way our organisations are managed that makes change so difficult?
- How can these systems problems be fixed so that more patients are not harmed?
In attempting to answer these guiding questions they conclude that rather than relying on what has been learned from the past, risk managers should attempt to chart a new future by creating a well-educated team who can anticipate and prevent adverse events from occurring in the first place (Kuhn and Youngberg 2002).
Effective risk management involves every level of the health service, so it is essential that all healthcare workers understand the objectives and relevance of the risk management strategies applicable to their own workplace (WHO 2011).
Yet whilst this is openly understood some authors suggest that current risk management education isn’t comprehensive enough to protect patient safety.
For example, Reason (2000), suggests that two approaches to the problem of human fallibility exist: the person and the system.
- The system approach focuses on the conditions under which individuals work, and tries to build defences to avert errors or mitigate their effects.
- The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, unsafe acts or procedural errors.
Naturally enough it’s focusing on person-based errors where education can have the greatest impact by increasing knowledge and reducing unwanted variability in human behaviour.
Traditionally, risk management education has placed great emphasis on fear-based strategies such as poster campaigns that appeal to people’s sense of fear, writing or amending yet more procedures, disciplinary measures and the threat of litigation as well as re-training. It’s an approach that can quickly lead to a culture of blame where errors are often treated as moral issues (Reason 2000).
Focusing on Facts May Not be Enough in Risk Management
Traditionally risk management education focuses on the facts that learners need to know, for example:
- How to report known risks or hazards in the workplace;
- How to keep accurate and complete medical records;
- When and how to ask for help from a supervisor, or senior healthcare professional;
- Participation in meetings that discuss risk management and patient safety;
- Responding appropriately to patients and families after an adverse event;
- Responding appropriately to complaints.
Whilst fact-based training sessions are immensely valuable, Levett-Jones et al. (2010) takes a broader view suggesting that greater focus should be placed on teaching clinical reasoning skills. For example, they suggest that although warning signs often precede serious adverse events there is consistent evidence that ‘at risk’ patients are not always identified or managed appropriately. This ‘failure to rescue’, with rescue being the ability to recognise deteriorating patients and to intervene appropriately, is often related to poor clinical reasoning skills.
The process of clinical reasoning can be summarised by the following key steps:
- Practitioners collect cues;
- Process the information;
- Come to an understanding of a patient problem or situation;
- Plan and implement interventions;
- Evaluate outcomes;
- Reflect on and learn from the process.
Effective clinical reasoning depends on the practitioners’ ability to:
- Collect the right cues;
- Take the right action;
- For the right patient;
- At the right time;
- For the right reason.
It’s these factors that provided the impetus for the development of an educational model with the potential to enhance students’ clinical reasoning skills and consequently their ability to manage ‘at risk’ patients (Levett-Jones et al. 2010).
Creating a Model of Clinical Reasoning
Steven et al. (2014) also reinforce the point that education is crucial to how practitioners’ practice, talk and write about keeping patients safe.
Yet, in a recent research study they discovered that within academic contexts patient safety was not always visible as a curricular theme. Rather than focusing on patient safety, litigation and the risk of losing the authority to practise were acknowledged as the drivers to update safety training. As a result, many students reported being taught idealised skills with an emphasis on ‘what not to do’.
Additional concerns also surrounded the fact that students who learnt from mentors or role models found it difficult to challenge their practice, opting instead to ‘fit in’ for fear of bad reports, or failing their placements. Steven et al. (2014) also flagged tensions linked to both formal and informal patient safety education and the potential to impact negatively on students’ feelings of emotional safety in their learning.
Johnstone and Kanitsaki (2007) also point out the need for greater education to help practitioners to manage clinical risks effectively. However, they also go on to say that just what form clinical risk management and safety education should take, remains an open question.
It’s a dilemma reflected by a surprising lack of research in this area. Clearly then, there is room for fresh and varied approaches to risk management education. For example, Streimelweger et.al (2015) proposes a new model of risk management based on the variability of human factors alongside more traditional methods. It’s interesting research which suggests that it may be possible to reduce the risk level of failures by placing greater emphasis on ‘human-factors’ via educational programs.
As Johnstone and Kanitsaki (2007) suggest without further good quality research it’s not possible to ensure that the educational programs currently offered on risk management are evidence-based or designed in a way to help practitioners develop the abilities they need to respond effectively to the complex challenges of patient safety and quality care.
It’s a situation succinctly summarised by Kuhn and Youngberg (2002) who suggest that despite the ever-greater challenges of smaller workforces, more complicated technology and increasing patient demands, healthcare professionals must always remember that patients and their families entrust their lives to them. It means that finding ways to limit and stop the unnecessary and preventable discomfort, disability, and death directly attributable to unsafe practice is a matter of urgent concern (Moss and Barach 2002).
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Johnstone, M.J. and Kanitsaki, O. (2007) ‘Clinical risk management and patient safety education for nurses: A critique’, Nurse Education Today, 27(3), pp. 185 – 191 [Online]. Available at: https://www.sciencedirect.com/science/article/pii/S0260691706000633(Accessed: 25.04.19).
Kuhn, A.M. and Youngberg, B.J. (2002) ‘The need for risk management to evolve to assure a culture of safety’, BMJ Quality & Safety, 11(2), pp. 158-162 [Online]. Available at: https://qualitysafety.bmj.com/content/11/2/158 (Accessed: 30.04.19).
Levett-Jones, T., Hoffman, K. and Dempsey, J. (2010) ‘The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients’, Nurse Education Today, 30(6), pp. 515-520 [Online]. Available at: 25.04.19 (Accessed: https://www.sciencedirect.com/science/article/pii/S026069170900210X).
Moss, F. and Barach, P, (2002) ‘Quality and Safety in Health Care: a time of transition’, BMJ Quality & Safety, 11(1), pp. [Online]. Available at: https://qualitysafety.bmj.com/content/11/1/1 (Accessed: 30.04.19).
Moskowitz, D. (2018) The Importance of Healthcare Risk Management, Available at: https://www.investopedia.com/articles/personal-finance/072315/importance-healthcare-risk-management.asp (Accessed: 30.04.2019).
Reason, J. (2000) ‘Human error: models and management’, BMJ, (320), pp. 768 [Online]. Available at: https://www.bmj.com/content/320/7237/768?ath_user=efschouston002&ath_ttok=%253CTPEEDaMygDfSrj8WwQ%253E(Accessed: 25.04.19).
Streimelweger. B., Wac, K. and Seiringer, W. (2015) ‘Improving Patient Safety through Human-factor-based Risk Management’, Procedia Computer Science Volume 64, 2015, Pages 79-86, 64(), pp. 79-86 [Online]. Available at: https://www.sciencedirect.com/science/article/pii/S1877050915026010 (Accessed: 25.04.19).
Steven, A., Magnusson, C., Smith, and Pearson, P.H (2014) ‘Patient safety in nursing education: Contexts, tensions and feeling safe to learn’, Nurse Education Today, 34(2), pp. 277-284 [Online]. Available at: https://www.sciencedirect.com/science/article/pii/S0260691713001627 (Accessed: 25.04.2019).
WHO Multi-professional Patient Safety Curriculum Guide (2011) ‘Understanding and managing clinical risk’, WHO Safety Curriculum, 6(), pp. 151-164 [Online]. Available at: https://www.who.int/patientsafety/education/curriculum/who_mc_topic-6.pdf (Accessed: 25.04.19).