The recent biomedical, technological, and normative changes have led healthcare

organizations to the implementation of clinical governance as a way to ensure the best

quality of care in an increasingly complex environment. Risk management is one of the
most relevant aspects of clinical governance and approaches put forward in literature
highlight the necessity to perform comprehensive analysis intended to uncover root causes
of adverse events.

Organizational leaders must become “systems thinkers” who demand in- depth
analysis of safety concerns, replace punitive reactions to mistakes with an open
environment and proactively address any risks; there will be an opportunity to build safer
health care organizations.

that may have a on the organization.

Anything that of the organizations to

It is the that will in the

adverse events and the effects of these events.

It is a to , , , and risks in
a , , and Manner.

The purpose of risk management is to

so that may be the adverse events.
Why we need risk management?

Increases the )‫ (احتماليه‬of achieving objectives.

(taking action in advance) management.
Improves customers’ and
Establishes for decision making and planning.
time, assets, budget and staff.
Protecting the and of the organization.
Increasing the of operations.
the and the

Risk Management can be Beneficial in the Following Contexts

Comprehensive risk management of the

organization from top down including financial and business viability.

(Such as; credentialing, privileging, job description, employee

insurance, trainings, medical coverage).
(Such as; job description, training, medical coverage).
(Budgeting, cost-benefit and cost-effectiveness analysis, insurance
coverage).
(Such as; organogram )‫(التخطيط الوظيفي‬, Job descriptions, delegation of
work).
(Such as scope, time, cost, human resources, operational,
procedural, technical, natural and political).
(Such as building safety, security of the facility,
hazardous materials and waste disposals, emergencies internal and external, fire safety,
medical equipment maintenance plan and maintenance plan for each
 Establish the context.
Identify risks Step.
Analyze risks Step.
Evaluate risks.
Treat/Manage Risks.

Context is very (Intensive

care unit), (Operation room), (Emergency room), blood transfusion services,
(coronary care unit), medication management including medication administration are

Risk identification is the whereby the and the

become in the health care and
environment.

The are in the also, sometimes

known as the

with department chiefs, managers and staff.

Patient )‫(تتبع‬ (Tracing the journey of a patient from admission till
discharge.
screening of patient . (Refers to the process of reviewing past
patient records).
Reports of bodies.
reporting system & (unexpected) events.
(HAI) reports.
reports.
Facility committee report.
Patient complaints and satisfaction survey results.
 (such as Morbidity and mortality committee,
medication management and use, Infection control, blood utilization, facility
management and safety committee).

Risk analysis is about of the risks identified. It

includes the following:

Level of the risk or Risk score.

Underlying causes.
Existing control measures.

When examining the existing control measures, should be given to

their , and in
to the These include all measures put in place to
the risk and may

Policies, procedures, protocols, guidelines.

Alarms and beeps.
Engineering controls.
Insurance coverage programs.
Code teams.
Trainings.
Emergency arrangements.
Preventative maintenance controls.

Represents a to the of
so that to
with a people still

For explanation only: Brainstorming, in the context of root cause analysis, is a

collaborative and creative problem-solving technique where a group of relevant and
informed individuals generate a large number of ideas or potential causes to identify the
underlying root cause of a problem or incident.
 Risk score is calculated by score with the of
score as below:

Likelihood scoring is the , and of

the the likelihood. it is important to
the risk. the ;

It should be noted that in the of a particular

materializing the Consideration should
be given to the number and robustness of existing controls in place, with evidence
available to support this assessment.

The assessment of occurring is

with and

Rare/Remote (1) Unlikely (2) Possible (3) Likely (4) Almost certain (5)

Frequency Probability Frequency Probability Frequency Probability Frequency Probability Frequency Probability

Occurs 1% Occurs 10% Occurs 50% Bi-monthly 75% At least 99%

every 5 every 2-5 every 1-2
years or years years monthly
more

Severity of the impact of , ,

, or the
The
One of the ways in which impact grades can be defined is the severity of the injury

For Example:
1-5 Low risk
6-12 Medium risk
15-25 High risk

In the above example Risk score (R) of

The purpose of risk evaluation is to

and to and the

Accepting a risk does not

Risks in a service may be accepted for a

The of the risk is so that within

available resources.
The risk is such that

The in risk treatment should be the

and the
and Risk treatment plan should have:

Proposed actions.
Resource requirements.
Person/s responsible for action.
Timeframes (Dates for actions to be completed and date for review.)
 The most are those which rede
so that the
of controlling the risk and/or

e.g. by preventative maintenance,

audit & compliance programs, supervision, policies and procedures, testing, training of
staff, technical controls and quality assurance programs.

through
(contingency plan is a back-up plan in case the identified risk actually takes
place), disaster recovery plans, off-site back-up, emergency procedures, staff training, etc.

Transferring the risk involves another of the

through , , ,

This is achieved by either

Once the risk management is in place,

is an

Monitoring and Reviewing utilizes the following sources of information.

Incident reporting.
Clinical Audit indicators.
Patient Tracers.
Safety rounds.
Patient complains.
Satisfaction survey.
Staff complains.
Medical records.
 Residual risk is the It’s
to an
The risk that’s left is residual risk.

in healthcare is which are of

the that healthcare Organizations risk
management are therefore a and
as Risk
management is of risks;
however it is challenging the following sense:

for ensuring risk management.

Risks are and
Risks are
of the risk management team with the employees and
processes
in the team.
for risk treatment/mitigation
in the process/system is
and systems are