Please watch the video on this link:
. Introduction
- Requirements:
– General background (establishing context, understanding and why this is a topic of interest).
- Introduction to subject matter of the assignment (more specific information on the matter being discussed).
- Introduction to contents of essay (an outline of what is ahead for the reader – “signposting”).
- 2-3 paragraphs (maximum 1-1.5 pages).
First we need to write an introduction about recognizing risks and improved patient safety based on Mildred story, why risk management is important, what are the benefits of risk management and an overview of the risk management process and the used methodology ICC or the Metalanguage. (refer to the HSE risk mngt policy and PDF Risk identification)
At the end of the introduction, please write, this paper will address the:
- Risks Mildred experience during her hospitalisation
- A practical, evidence-based framework to lead and engage staff in QRPS initiatives.
- Evidence-based healthcare risk management best practice.
- Risk identification.
- Risk estimation and evaluation (assessment).
- Risk control and acceptance (including residual risk calculation).
‐ 1 Establishing the Context
- Establishing the context means to define the external and internal factors that the hospital and its services must consider when they manage risk in specific Mildred experience.
- The Hospital’s external context includes its external stakeholders, for example, the Department of Health and other government departments, the legal and regulatory framework that applies to healthcare delivery, political, economic, technical and demographic influences.
- Its internal context relates to its governance arrangements, contractual arrangements, , its capacity and capability, internal policies and procedures including Corporate Safety Statement, Human Resources, Clinical/Care policies, framework arrangements with unions, etc. Context can also relate to a specific service and the factors that must be considered when managing a risk for example handover between the staff, surgery booking, consenting process, identification process, fall prevention program etc.
Risk identification:
I have Identified 4 risks from Mildred story:
Patient safety (fall).
Ineffective communication/poor patients hands-off among healthcare team
Legal risk (consenting)
Patient safety (Improper patient identification)
| Risk | Description |
| Patient safety (Fall) | Mildred is a high-risk patient, with neurological impairment can’t ambulate alone without assistant, bed side rails are not raised to prevent patient fall during the hospitalisation. No fall risk bracelet applied , Wet Floor ,etc. |
| Patient safety (Healthcare associated infection) | HSO resident or nurse in charge for Mildred didn’t follow the Operating theatre protocol, no antibiotic given prior to the surgery |
| Ineffective communication/poor patients hands-off among healthcare team | Improper handover between the Dr Smor and HSO resident, paramedic and the receiving nurse. Absence of multidisciplinary approach in treating a stroke case. The on-call doctor didn’t examine her, wrote any note or even consulted the appropriate personal like dietitian, physiotherapist, neurologist, cardiologist, anaesthesiologist etc. Not using the ISBAR tool |
| Legal risk (consenting) | George is not the appropriate person to sign for invasive surgical procedure for Mildred (George is her care giver not her legal guardian) Also, the HSO resident didn’t explain what the potential risks, benefits of the surgery are. Moreover, HSO resident wrote wrong surgery site, once George informed him about the mistake, he did overwrite which is a wrong practice. |
| Patient safety (Improper patient identification) | No bracelet applied for the patient upon arrival. Failure to comply with the international patient safety goal number 1 that relies on three identifiers: Patient Name, Date of birth, medical record number for booking a surgical procedure. |
| Patient safety (Pre-anaesthesia clearance) | Mrs Mildred is a high-risk case as she is having pre-existing medical problems like unstable angina, stroke. The pre-operative assessment is crucial as it uncover any potential health issue and optimise patient safety, by doing so the anaesthesiologist might do more lab test, imaging and consultation for the other team members such as cardiologist, neurologist etc.. |
- Critical, evidence-based introduction and definition of what this step is in the Group’s risk management activity (should include the evidence-based methodology used in generating the Group’s risk statements) – maximum 1 x paragraph.
- 4 x risks to be identified and classified/categorized (evidence-based).
- Ensure all risks identified are critically constructed to fully meet the criteria of the methodology selected and are 100% supported by the evidence identified by the Group in “Mildred’s Story” (demonstrating critical Group understanding of context, content, etc.).
- For the output of this heading (and potentially including the next “5. Risk estimation and evaluation”), Group’s should consider presenting a table (similar to a traditional “risk register”) remembering once again that words in assignment tables, figures, graphics, etc. are not included in the word count, MUST be correctly titled and referenced – and MUST be referred to from the narrative!
- Where a table is used, and it crosses pages, please make sure that the header row is repeated at the top of each page (much easier for the reader to follow!).
Table 4.1: Case study risk identification
| Risk Id. | Risk classification | Risk statement | Reference to the case study |
| 1 | Classification (using an evidence-based methodology!). | Here is your risk statement (using an evidence-based methodology!). | Information providing insight into where this risk was identified in the case study. |
| 2 | |||
| 3 | |||
| 4 |
Recommended articles,
ISBAR Tool/ Handover process:
CONSENT FORM PROCESS
Fall and Injury Management of Patients with Stroke
Morse Fall scale
Patient identification:
