Risk Management Summary

1. Progress and Challenges Ahead

Risks and threats are pervasive in the healthcare system because of human interactions with complex systems and the constant barrage of new technologies, cybersecurity, demands from regulators, and the fast pace of medical science. It is clear that, despite our most valiant efforts, we still have far too many medical errors. It is up to risk management to conduct threat assessments and work with expert teams to improve patient safety and save lives and mitigate risks to an acceptable level. Traditionally, risk management programs have been reactive, but they need to be 90 percent proactive with quality and patient safety, and only 10 percent reactive to situations in which our defenses have failed. Our approaches need to change by moving to ERM so the entire system can be viewed and we can protect not only our assets but more importantly our patients. We also need to innovate and develop evidence-based risk management solutions to be successful in our aim of “Getting to Zero” serious events.

Ultimately, we cannot move forward without first developing a Safety Culture. Such a culture is the basis for successfully changing an organization into a Highly Reliable Organization. We need effective leadership with a commitment to psychological safety, just culture, and accountability; a learning system with transparency; reliability built into our system design with a focus on the end user; improvement strategy and measurement; and continuous learning to deliver safe and reliable care. Patients, employees, and clinicians need to be an engaged and integral part of this transformation. This takes hard work and commitment; it is not for the weak of heart. It is a journey worth taking because our patients, clinicians, and staff deserve the very best from our healthcare system.

big idea

We can do better; it is up to all of us to play our part in realizing the aim of zero harm. This is not a time to sit in the wings, but to be an active participant and champion the movement.

2. Resources

For further information on risk management, visit

• Kaiser Permanente: Garfield Innovation Center
• Medical Mutual: Risk Management Plan
• ECRI: Risk Management Plan
• Risk Management Risk Assessment and Analysis Tool
• American Society for Health Care Risk Management (white papers on disclosure of unanticipated events, ERM, Getting to Zero, Patient Safety Event Reporting, Lessons learned, Harm classification, Toolkits)
• ECRI: Safety and Quality evidence-based care
• The Joint Commission: Standards of National Patient Safety Goals

Support

If you are struggling with a concept or terminology in the course, you may contact RiskManagementSupport@capella.edu for assistance.

If you are having technical issues, please contact learningcoach@sophia.org.