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Healthcare risk management grew out of the insurance crisis of the 1970s. During that period liability premiums skyrocketed, due in part, to the dissolution of the doctrine of charitable immunity, which historically protected a hospital's assets from lawsuits.1 Thus, risk management has historically been about protecting the hospital and preventing financial loss. It has evolved to include a primary focus on protecting the patient and preventing harm. This protection is termed value protection and remains a challenge today. The future is not only about value protection, but also about value creation—the ability to demonstrate the return on risk, or the upside of risk management. This chapter will primarily focus on value protection in emergency medicine, and will also describe the opportunity to demonstrate value creation.

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Like the malpractice crisis of the 1970s, the patient safety movement today is creating change in risk management. One of the greatest catalysts has been the Institute of Medicine's 1999 report, To Err Is Human: Building a Safer Health System. This report provided insight into the growing problem of medical errors, which then lead to the rise in mounting regulations and government scrutiny.2 Today, providers must meet an unprecedented and increasingly prescriptive standard of care. The evidence used to determine if a provider acted as a reasonably prudent provider now potentially includes standards created through advancing regulatory and accrediting agencies. Even more challenging is the need to transform the hierarchical healthcare environment into a culture of patient safety.

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The key to implementing effective risk management rests on the ability of leadership to establish a culture of patient safety and risk reduction. There must be a belief that the majority of risk issues are a result of system failures, and that they must be managed within a just culture framework. This framework is based on accountability, specifically a shared accountability where there is a balanced approach between the focus on system issues and human error. In this culture, everyone must understand that risk is, for the most part, both predictable and preventable. This belief will aid in the adoption of prevention tools to decrease variation and to standardize operational process.

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Risk management is interdisciplinary and affects all aspects of the organization. Risk issues in the emergency department (ED) can stem from operational, clinical, and/or communication issues that all contribute to system errors. Through the implementation of a proactive approach to risk management and patient safety, adverse outcomes can, and have, been prevented.

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A proactive risk management program requires the development and execution of strategies to address the high-risk areas. The risk management process is a 5-step process listed in Box 94-1.

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Box 94-1 The 5-Step Risk Management Process
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In order to demonstrate the use of the risk ...

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