risk assessment and management in nursing

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• > Risk assessment in clinical practice: a framework for...

Article contents

Learning objectives, case vignette, meaning of risk and related concepts, risk assessment framework, conclusions, author contributions, declaration of interest, risk assessment in clinical practice: a framework for decision-making in real-world complex systems.

Published online by Cambridge University Press:  29 September 2022

Risk assessment in clinical practice is often characterised as a process of analysing information so as to make a judgement about the likelihood of harmful behaviour occurring in the future. However, this characterisation is brought into question when the evidence does not support the current use of risk assessment approaches to predict, or provide probability estimates of, future behaviour in a way that is usable in single instances arising in individual cases. This article sets out a broader and more clinically applicable description of risk assessment which takes account of the wider influences on how this clinical activity takes place. In so doing, it provides a framework to guide clinicians, researchers and authors of practice guidance who are interested in improving approaches to risk assessment.

After reading this article you will be able to:

• explain the concept of risk as it applies to clinical practice

• recognise that risk assessment is much more than gathering and interpreting information to make judgements about future harm

• understand the wider psychological, interactional and system influences on risk assessment in a way that informs better practice.

Clinical risk assessment in the field of mental health is usually conceptualised as a process carried out by clinicians which involves the explicit analysis of pertinent information about a patient to reach a judgement on whether the patient will go on to act in a way that is harmful to themselves or others. This conceptualisation imagines an objective process disconnected from the real-world context in which the assessment occurs. A more informed perspective should delineate the way such judgements may be reached and the influence on doing so of the wider context in which the clinical encounter occurs. This article offers such a perspective in a way that encourages clinicians, organisations and researchers to approach risk assessment differently.

The risk assessment framework described below starts with a description of information gathering. The risk assessor needs to be familiar with factors that have been found to be associated with harm to self or others. These have been described extensively elsewhere (e.g. American Psychiatry Association 2016 ; Franklin Reference Franklin, Ribeiro and Fox 2017 ) and will not be rehearsed here. The focus of this article is more on how this information should be interpreted in the context of making clinical decisions, and the importance of recognising the impact of broader interpersonal and organisational issues on the day-to-day practice of risk assessment ( Fig. 1 ). Drawing on the empirical evidence base and on clinical experience, we will demonstrate that clinical risk assessment should not be seen as an objective analysis of risk factors to make a prediction about whether or not the patient is going to harm themselves or others in order to decide what to do to prevent that outcome. Rather, it should be seen as a process of gathering and interpreting information in the context of interpersonal relationships to guide collaborative decision-making that aims to improve patient well-being while reducing the likelihood of harm to self or others.

FIG 1 Risk assessment framework.

In academic and practice guidance the notion of risk is often examined in a way that is somewhat removed from real-world clinical practice (Nathan Reference Nathan, Gabbay and Boyle 2021b ). Key points raised in this article will be examined with reference to practice by using a case vignette that involves possible future harm. Rather than presenting only a patient profile, the following vignette describes a broader set of processes that are often neglected in risk assessment guidance and research and that will be explored in this article.

At the request of the hospital medical team, a liaison psychiatry practitioner Amy assessed Tom, a 37-year-old male who had been deemed medically fit following treatment for an overdose of medication and alcohol. Amy elicited a history of alcohol misuse, depressive symptoms and relationship breakdown. Tom said that he wanted to come into hospital for help to stop drinking. On the basis of her assessment of Tom's ongoing depressive symptoms, his social isolation and the level of his hopelessness and despondency, Amy was concerned about the risk to self and she thought that a brief crisis admission should be considered even though she was mindful that there were no vacant beds in the local psychiatric unit. Nevertheless, according to the local protocol for patients thought to need hospital admission, Amy made a referral to the home treatment team that acted as the ‘gatekeepers’ for acute in-patient services. A member of that team undertook an assessment and concluded that the primary problem was alcohol misuse, which was not a reason for admission to a psychiatric unit. When this was explained to Tom, he became angry and he said that if he was not admitted to hospital he would go out and throw himself off a motorway bridge.

To effectively undertake risk-related activities (such as risk assessment and management), we need to be sure that we agree on the meaning of the term ‘risk’. Formal definitions of risk in the context of mental health service provision refer to a future harmful event and generally incorporate its severity, imminence and likelihood or probability. However, we cannot take for granted that the notion of ‘risk’ is applied consistently in clinical practice. A phenomenological analysis of the Royal College of Psychiatrist's report on the assessment and management of risk to others (Royal College of Psychiatrists 2016 ) found that ‘risk’ was used in a way that conveys variable meanings (e.g. harm, the possibility of harm, characteristics of possible harm, a state with changeable potential for harm, and different states of potential harm) (Nathan Reference Nathan, Gabbay and Boyle 2021b ). Given the potential for protean interpretations of ‘risk’, we believe it is essential that clinicians, academics and authors of practice guidance are clear about their use of this term. In this article, the term risk is used to describe the ‘possibility of harm’. This conveys that something may occur without necessarily suggesting that it is likely to occur (i.e. it is ‘possible’ but not necessarily ‘probable’) and it leaves room for the further characterisation of the possibility.

To be able to characterise future harmful events, it is first necessary to commit to the types of event under consideration. Guidance does not usually describe this step, but it would seem reasonable to at least consider types of harm suggested by expressed intentions (e.g. Tom's statement about throwing himself off a bridge), a recurrence of harm that has occurred before (e.g. an overdose), other forms of the same category of harm (i.e. other suicidal behaviours) and other categories of harm given a particular mental state (e.g. harm to others linked to Tom's angry hostility). Risk assessment convention dictates that the possibility of any identified plausible future harmful events occurring should be delineated. Therefore, clinicians need to understand different ways of describing the delineation ( Box 1 ) and ensure that their use of a chosen descriptor is valid.

BOX 1 Meaning of risk, prediction, probability and related terms

Risk – The possibility of harm

Prediction – A commitment to a specified future outcome

Probability :

• Classic probability – The fraction of the total number of possibilities of equal likelihood in which the outcome occurs

• Frequentist probability – The frequency of an outcome over a long-run series of event occurrences

• Subjectivist probability – The degree of belief that a specified outcome will occur

Uncertainty – Known and unknown characteristics of the future in which the outcome occurs

Propensity – A property that is causally responsible for the long-run frequency

A judgement about whether an event may occur in the future could be presented as a dichotomous prediction, i.e. that harm will or will not occur. Alternatively, judgements about the future could be categorised (e.g. low, medium or high risk). However, such categorical approaches have limited utility in informing clinical decisions so as to meaningfully reduce infrequent high-harm events (Mulder Reference Mulder, Newton-Howes and Coid 2016 ).

Classic probability

The chance of a possible event occurring can also be characterised in terms of probability, which is used to describe the relative frequency of an event. This classic interpretation of probability is the fraction of the total number of possibilities of equal likelihood in which the event occurs (e.g. a 1/6 probability of tossing a three with a fair die). Since the assessment of possible future harm in clinical scenarios such as the case vignette described above does not involve a fixed number of outcomes of equal likelihood, classic probability is not applicable.

Frequentist probability

A related interpretation of probability is the frequentist view, which represents probability as a ‘long-run frequency over a large number of repetitions of an experiment’ (Blitzstein Reference Blitzstein and Hwang 2019 ). This would produce the same probability of tossing a three with a fair die, but it could also be used to reach an informed probability for an outcome when rolling an unfair die (i.e. where the possibilities are not equally likely). Clinical scenarios such as the one presented in the vignette are unique instances that cannot be replayed. Thus, even putting aside the obvious ethical objections, allowing a series of instances to play would not be the same as rolling the same die in an unchanging environment. Therefore, frequentist probability is meaningless in a unique clinical situation. However, there remains a question about the applicability to practice of data-sets from comparable groups of patients. For instance, in relation to a discrete outcome such as suicide, one could use the positive predictive value of a suicide risk assessment model derived from group-level data as the probability of a patient identified as ‘high risk’ subsequently dying by suicide. However, once it is recognised that a patient presentation at a point in time is a unique instance and that the patient's future will be influenced by a unique set of countless environmental and psychological factors in constant interplay, the limitations of using a data-set to inform decision-making in a single clinical encounter become apparent (Nathan Reference Nathan, Gabbay and Boyle 2021b ).

Uncertainty

Economists have long recognised that probability in the classic or frequentist sense cannot be used for decision-making in the context of a single unique instance (Sakai Reference Sakai 2016 ). Frank Knight reserved the term ‘risk’ for those scenarios in which the probability distribution of the outcome is known, and instead used the term ‘uncertainty’ for those scenarios in which the situation is so unique that probability distributions are not available (Sakai Reference Sakai 2016 ). Critically in the context of mental health risk assessments, Knightian uncertainty seems more applicable since we cannot reliably distinguish what will occur from what will not occur. This uncertainty has two underlying components: epistemic uncertainty, resulting from a lack of knowledge, and aleatory uncertainty, resulting from random or chance events (Large Reference Large, Ryan and Carter 2017 ). If it is accepted that one cannot accurately determine much of what is going to happen in the future (including events that might have a bearing on the occurrence of harm-related outcomes), then it follows that much of the uncertainty about a particular future harm-related outcome is aleatory (Large Reference Large, Ryan and Carter 2017 ). The vignette illustrates that in such clinical settings the uncertainty arises in a scenario involving agents making interdependent choices with strategic dimensions. This raises as yet unanswered questions about whether game theory modelling might offer greater insights into likely outcomes. To do so, account would need to be taken of the role of emotions in decision-making.

Subjective probability

Another interpretation of probability that does not rest on an imagined or actual series of trials is subjective probability. In this case, probability is conceptualised as a feature of the person undertaking the assessment rather than of the real world and is quantified on a scale of the degree of belief (Biedermann Reference Biedermann, Bozza and Taroni 2017 ). For instance, in the case vignette above, Amy felt that Tom should have a brief crisis admission, whereas the home treatment team practitioner felt otherwise. This discrepancy in opinion could be understood as arising owing to differences in both Amy's and the home treatment team practitioner's prior assumptions. Amy may have recently seen a very similar patient who subsequently died by suicide, therefore leading her to believe that Tom is presenting as higher risk warranting admission.

One may also consider the properties of the entity that are causally responsible for the long-run frequency (such as the physical property of a rolled die). This is known as propensity. The propensity notion has advantages over the frequentist perspective because it can be used for a single event. Its use in mental health scenarios would also encourage a focus on the mental processes (the properties that are causally responsible for action) and, by extension, on consideration of factors that might influence these processes. In this way, talk of propensity shifts the focus from abstract disembodied concepts (such as probability) to the mind of the person.

Information gathering

Risk assessment should not be seen as a stand-alone clinical activity. It is heavily dependent on a comprehensive psychiatric assessment, which involves integrating information from an interview with, and examination of, the patient together with data from other sources (e.g. personal and professional informants, and the available records). Certain parts of that assessment are especially pertinent to judgements about the possibility of harm. These include psychological, behavioural or environmental occurrences, which have been found in group-level quantitative studies to be associated with an increased likelihood of future harm to self or others (American Psychiatry Association 2016 ; Franklin Reference Franklin, Ribeiro and Fox 2017 ). For instance, these studies have demonstrated that some of the elements contained in the case vignette are associated with an increased likelihood of suicide: these include a history of overdose, comorbid psychiatric disorder, alcohol misuse, relationship breakdown and feelings of hopelessness.

Special attention should be given to the characteristics of violent or suicidal ideation (e.g. frequency and intensity) and associated behaviours (e.g. intent, planning, actions) (Borges Reference Borges, Nazem and Matarazzo 2019 ). Suicidal ideation refers to thoughts about ending one's life, which may be categorised as ‘active’ (i.e. thoughts, and a plan, to die) or ‘passive’ (i.e. thoughts to die, but no plan) (Turecki Reference Turecki, Brent and Gunnell 2019 ). Although the clinician should pay attention to any statements suggesting a pattern of thinking, feeling and planning that is relevant to the potential for future harmful actions, it should also be recognised that internal experiences relevant to future actions are not experienced as circumscribed and unchanging entities in the way descriptors such as active or passive ideation suggest. Similarly, taking a phenomenological approach to explore mind-based correlates of disturbed behaviour is likely to lead to a more fine-grained and case-specific causal understanding of the behaviour than is possible when working just at the level of diagnosis or symptoms (Nathan Reference Nathan, Whyler and Wilson 2020 ).

If an assessment entailed merely compiling a list of case-based factors that theoretically may increase the likelihood of a high-harm outcome, it would be of limited use for decision-making in an individual scenario (American Psychiatric Association 2016 ). Instead, the relevance of these factors should be understood in the context of the person's current experiences and triangulated with other sources of information, such as a collateral history from a family member. Moreover, the assessment should attempt to uncover underlying psychosocial processes that explain how the factors interact to influence this person's behaviour (as explained below).

Interpretation

Despite the identification of factors that predict suicide or serious violence, it has not been possible to translate this literature into clinically useful predictive tools (Mulder Reference Mulder, Newton-Howes and Coid 2016 ). Although a meta-analysis of prospective studies predicting suicide following self-harm found four risk factors with robust effect sizes (previous self-harm, suicidal intent, physical health problems and male gender) they were ‘unlikely to be of much practical use because they are comparatively common in clinical populations’ (Mulder Reference Mulder, Newton-Howes and Coid 2016 ). The study's authors, who also reviewed a range of risk scales, concluded that ‘the idea of risk assessment as prediction is a fallacy and should be recognised as such’. Another meta-analysis concluded that no unique set of risk factors could be reliably linked to an outcome of suicide, with predictive ability found to have not improved over the past 50 years (Franklin Reference Franklin, Ribeiro and Fox 2017 ). There are a number of reasons. First, risk factors are non-specific and are shared by many individuals; for instance, the presence of mental illness is considered a risk factor for a suicide, despite the fact that most people with mental illness will not die by suicide (Franklin Reference Franklin, Ribeiro and Fox 2017 ). Second, suicide risk is influenced by a complex combination of interacting factors, with each individual factor only having a weak association with the rare outcome of suicide (Zortea Reference Zortea, Cleare and Melson 2020 ). Third, although clinicians are tasked with determining risk over periods of hours or days, most studies are not focused on acute or short-term prediction and therefore, unsurprisingly, longer follow-ups within studies did not improve prediction power and, in some cases, significantly weakened it (Ribeiro Reference Ribeiro, Franklin and Fox 2015 ). It should be mentioned, though, that a case has been made for the use of probability scores from a risk assessment tool to complement an individual needs-based assessment, although how the clinician uses the scores requires further empirical examination.

Believing that it is possible to categorise patients accurately may even be harmful. Potential problems include unnecessarily applying more restrictive approaches to all those categorised as ‘high risk’ and directing resources away from the ‘low-risk’ groups despite these groups containing most of those who go on to die by suicide (because they are much larger in absolute terms) (Mulder Reference Mulder, Newton-Howes and Coid 2016 ). Additional problems may arise as a consequence of an innate tendency of humans to automatically assign people to broad categories and then to make predictions about them on the basis of the assigned category rather than person's unique characteristics (Liberman Reference Liberman, Woodward and Kinzler 2017 ). In the risk assessment/management context, this may lead to the clinician inflexibly adhering to beliefs about the patient's assigned risk categorisation even in the light of emerging evidence to the contrary. As will be discussed below, such inflexibility can encourage a countertherapeutic stance. In forensic mental health services, risk categorisation is still used, but its effectiveness in reducing violence remains to be determined (Challinor Reference Challinor, Ogundalu and McIntyre 2021 ).

Uncertainty versus predictions and probabilities

Although there may be an emerging consensus that categorical prediction has no place in an individual clinical risk assessment in general psychiatric settings (e.g. Graney Reference Graney, Hunt and Quinlivan 2020 ), there remains a question about the role of probabilistic approaches. In other fields, such as economics and geopolitics, it has been demonstrated that the practice of actively thinking probabilistically is associated with more accurate subjective probability estimates of future events (Tetlock Reference Tetlock, Mellers and Scoblic 2017 ). However, there is a difference between improving the accuracy of these estimates and the use of the estimates to inform clinical decisions. To use a probability estimate to inform a categorical decision (e.g. to admit the patient or not) requires a threshold to be applied, which inevitably turns the estimate into a category (and therefore subject to the problems of using predictive categories).

The concept of ‘uncertainty’, which acknowledges that the probabilities of the outcomes are unknown or meaningless (Park Reference Park and Shapira 2017 ), more accurately represents the realm in which mental health clinicians undertake risk assessments and it encourages a focus on reducing uncertainty rather than predicting outcomes or quantifying the probability of their occurrence. Accepting that we are dealing with Knightian uncertainty, in that the probability distribution of future harmful events in the case of a given patient is unknown, reduces our need to think of the future in terms of predictions and probabilities. The focus should then shift from trying to compute the likelihood of outcomes to instead concentrating on characterising future scenarios of interest and the circumstances that would appreciably increase the likelihood of harm. In the psychiatric context, this can be facilitated by formulation, which brings together relevant factors in a way that produces an explanatory framework for the behaviour of interest. This is commonly done by assigning factors different explanatory functions, such as predisposing, precipitating, perpetuating and protective. Using formulation as an explanatory framework and scenarios to speculate about the future are important steps in approaches to risk assessment and management in forensic settings. Formulations can be further enhanced by exploring the proximal mental processes that are hypothesised to cause the behaviour (i.e. the propensity) (Nathan Reference Nathan, Whyler and Wilson 2020 ). Existing explanatory models of suicidal and violent behaviour can serve as evidence-based frameworks to assist the clinician (Klonsky Reference Klonsky 2018 ) ( Box 2 and Table 1 ). Such models describe how combinations of many risk factors create pathways towards the emergence of harmful ideation and behaviour, and reserve particular focus, as a result of being set within the ideation-to-action framework, on the factors that govern the transition from ideation to action (Zortea Reference Zortea, Cleare and Melson 2020 ).

BOX 2 Explanatory frameworks of proximal mental processes related to suicidal behaviour

Interpersonal theory of suicide (IPTS) (van Orden Reference van Orden, Witte and Cukrowicz 2010 ) – Thwarted belongingness (unmet need to belong) and perceived burdensomeness (perception of being a burden to others) lead to suicidal desire. Exposure to painful and provocative events (e.g. childhood adversity, adult trauma, self-injury) causes habituation to fear and pain, which can result in the capability to enact suicide.

Integrated motivational-volitional model (IMV) (O'Connor Reference O'Connor and Kirtley 2018 ) – A tripartite model in which (1) the pre-motivational phase, comprising life circumstances and events, provides a contextual background for (2) the motivational phase, when defeat and humiliation appraisals lead to a state of entrapment in which suicidal behaviour is seen as a salient solution to life circumstances and suicidal ideation and intent develop, followed by (3) the volitional phase, in which the suicidal behaviour occurs. Progression through these phases is influenced by moderators (e.g. social problem-solving, memory biases and rumination, thwarted belongingness, burdensomeness, social support).

Three-step theory (3ST) (Klonsky Reference Klonsky 2018 ) – Step 1: the combination of pain that is experienced as punishing (particularly psychological pain consequent on aversive stimuli, such as conflict, loss, physical ill health) and hopelessness (about the pain diminishing) lead to suicidal ideation; step 2: suicidal ideation is heightened by disrupted connectedness (primarily to other people, but also to a job, project, interest, etc.); and step 3: progression from ideation to action depends on suicide capacity, which is made up of the dispositional (e.g. pain sensitivity), acquired (e.g. habituation to experiences associated with pain) and practical (e.g. knowledge of and access to lethal means).

Fluid vulnerability theory (FVT) (Rudd Reference Rudd and Ellis 2006 ) – Takes account of the variable nature of suicide risk over time (such as rapid changes in ideation) by delineating chronic and acute suicide risk. Acute episodes of risk are time-limited and driven largely by situation and contextual variables (e.g. severity and mix of current symptoms, life stressors, substance misuse, access to method). Chronic (or baseline/residual) risk describes an enduring individual vulnerability for suicidality or an acute risk episode and is based on a disparate range of factors, including adversity, genetic history, biology/physiology, and cognitive, affective and motivational dispositions.

TABLE 1 Explanatory framework of mental processes related to violent behaviour

Making use of case-based explanatory models

Although clinical experience suggests that the explanatory models (or elements thereof) often have utility in explaining a single instance of behaviour, a model should not be seen to have universal applicability and there should not be indiscriminate top-down imposition (Hjelmeland Reference Hjelmeland and Loa Knizek 2019 ). Furthermore, just because a model may represent a parsimonious theory to understand the behaviour in a way that guides clinical decision-making does not mean that it leads to highly accurate predictions of future behaviour (Klonsky Reference Klonsky, Saffer and Bryan 2020 ). Analysis of previous suicidal, self-harm or aggressive behaviours should inform the explanatory processes that are relevant to this case. This can be done using a chain analysis, which involves a collaborative exploration with the patient of the vulnerability factors and prompting events for, and the consequences of, the target thoughts/behaviour (Borges Reference Borges, Nazem and Matarazzo 2019 ). The use of such explanatory models can be illustrated in the context of the vignette presented above. It turned out that Tom's feelings of hopelessness and despondency tended to become more intense when the relationship problems were such that he could not see a way out of his predicament and an end to his anguish. If Amy was familiar with the evidence-based explanatory frameworks related to suicidal behaviour (and in particular the integrated motivational-volitional model), then she would be more likely to ask relevant questions and to explore further for other relevant processes (e.g. defeat and humiliation). Tom may, in response, feel reassured that his problems are being properly understood and he may be left with more insight into why he sometimes experienced thoughts of ending his life (which otherwise may have felt frighteningly unpredictable).

Even with the use of an agreed model to characterise possible future scenarios, within- and between-assessor differences may contribute to variability among assessor judgements. For example, affective processes, which may change over time in the same individual, have a strong influence on risk perception (through the automatic deployment of the affect heuristic). Thus, clinicians’ feelings (as distinct from their knowledge) about an intervention are liable to influence their perception of its effectiveness (including in relation to managing the potential for harm). Risk perception may also be dependent on the readiness with which examples relevant to the scenario under consideration come to mind (i.e. the availability heuristic), which is liable to differ depending on the assessor's previous experience. Assessors should be aware of the potential for biased judgements and the need to resist automatic risk categorisations in favour of a detailed analysis with the intention of reducing uncertainty.

As well as the effect of heuristics on decision-making, certain practitioner characteristics have been shown to contribute to better judgement formation. Subject-matter expertise is necessary, but not sufficient (Tetlock Reference Tetlock, Mellers and Scoblic 2017 ). For instance, an individual's willingness to accept the role of change and the potential to cultivate this type of judgement formation, together with active open-mindedness, are associated with better judgements about future events (Tetlock Reference Tetlock, Mellers and Scoblic 2017 ).

Decision-making

Although any categorical or dimensional outputs of risk assessment methods may not be usable in individual instances of clinical decision-making, the constituent elements of the risk assessment may still have some utility for risk management. Risk management involves addressing current modifiable factors that the explanatory formulation suggests increase the likelihood of high-harm behaviour, including any specific treatment needs (e.g. depression or substance misuse) (Large Reference Large, Ryan and Carter 2017 ). Ways of bolstering factors that the formulation suggests reduce the likelihood of future harm should be explored with the patient. The management plan should also consider early warning signs for a high-risk mental state and steps to be taken in this event. Specific safety or crisis plans (which focus on stressors, warning signs, self-management strategies, social support and crisis resources) have been shown to reduce subsequent suicidal behaviours (e.g. Nuij Reference Nuij, van Ballegooijen and de Beurs 2021 ).

Although it has to be accepted that the current empirical evidence undermines the case for the routine clinical use of categorical risk predictions, it does leave an outstanding question about how clinicians should take account of risk when faced with options that can only be implemented in categorically distinct forms. In the vignette presented above, one of the issues under consideration was admission to hospital. Clinical experience would suggest that the decision is often framed as being dependent on whether or not the patient is going to imminently act on urges to cause harm (to self in the vignette) but, as has been explained, this cannot be accurately predicted. It is possible to conceive the use of a probability estimate, but it would require the data-set from which the estimate is drawn to be relevant to the scenario (i.e. from a sample of patients assessed following an overdose rather than an in-patient sample about to be discharged). Also, to use a number from a continuous scale to make a categorical decision requires the establishment of thresholds (with or without the scope for justified discretion). Before introducing such an approach, further empirical testing would be necessary.

An alternative approach would be to use the unique case-based explanatory formulation in collaboration with the patient to consider the factors that increase the likelihood of the behaviour and potential ways to address modifiable factors so as to reduce that likelihood. It would still be necessary to come to a categorical decision, but this approach has the advantage of focusing attention on what can be done to adjust the modifiable circumstances (and this may include the use of therapeutic skills during the assessment), which in turn may assist the clinician in combatting their own automatic and biased categorical assumptions.

It needs also to be recognised that in practice the system places demands on the clinician that are sometimes in competition. Although the imperative to help the patient's emotional well-being may not conflict with the requirement to reduce the likelihood of high-harm outcomes, sometimes it does. For example, although admission may be thought necessary to manage dangerous levels of self-harm, in some cases the in-patient environment may exacerbate some of the underlying processes contributing to self-harm. For example, the use of medication and/or physical restrictions to address acute mental state changes may reinforce certain pre-existing processes contributing to a tendency to self-harm (such as difficulties understanding and reflecting on the mental states of others, which may lead to a dependence on the overt physical representations of the intentions of others provided by medication and physical restrictions). Therefore, the clinician needs to consider the possibility that the way of managing the potential for harm in the short term (i.e. admission) will further compromise the patient's well-being. Also, there may be service-level pressures (which can be manifest in interpersonal tension between ‘referrers’ and ‘gatekeepers’) to avoid admission, which are often related to the need to manage a finite resource under pressure. Thus, the clinician's final decision is influenced by judgements about future unpredictable harms and benefits within a complex system of pressures and relationships.

Interaction

If risk assessment is framed solely as a process of gathering and interpreting information about the patient to reach a judgement about the possibility of future adverse incidents, then the discussion with the patient is liable to become transactional, in that the primary goal is to elicit information. To the contrary, the interaction should be seen as an opportunity to reach a shared understanding of risk and to positively influence the patient's mental state and their representations of mental healthcare professionals in a way that may have a bearing on their future behaviour (including behaviour that has the potential to harm themselves or others). The clinician should adopt a compassionate and collaborative stance in which they actively and supportively listen with the aim of enhancing understanding (or reducing uncertainty) rather than reaching a categorical position about risk (Large Reference Large, Ryan and Carter 2017 ).

There may be a legitimate difference of view between the clinician and patient about the next steps (e.g. whether to admit a patient who is feeling suicidal), but the clinician needs to be careful that their explanation for their decision does not constitute invalidation of the patient's experiences. The false belief that the patient can be definitely allocated to a risk category may lead the clinician to have an undue sense of confidence in their judgement, and then convey this false confidence to the patient in a way that invalidates the patient's experiences and feelings. There is empirical evidence to show that a collaborative assessment that emphasises respect, compassion, curiosity, a desire to help, flexibility and the relational nature of the assessment is associated with symptom reduction and patient self-enhancement (e.g. Durosini Reference Durosini and Aschieri 2021 ) and it has been proposed that a positive therapeutic relationship may reduce risk (Royal College of Psychiatrists 2016 ).

Learning and investigating

The approach to learning from untoward incidents is relevant to the practice of risk assessment because in making decisions in acute psychiatric scenarios, clinicians are influenced not only by the clinical information available to them, but also by the wider context in which they practice (Nathan Reference Nathan and Wilson 2021a ). Such learning, typically through investigations, takes a deterministic perspective that does not readily apply within complex systems (such as mental health services), in which the underlying determinants of change are uncertain and non-stationary.

Although scrutinising the past in light of the outcome seems the best way to reach an explanation of why the outcome occurred, it can lead to problems when judging whether the decision was the correct one or not. The usual approach to investigating an incident (e.g. by an internal investigation, an external review or the coronial process) is to work back from the outcome to identify factors and decision points that appear to have a causal link with the outcome. This approach encourages decision-making to be tested in light of the outcome, i.e. would the outcome have been different if a different decision had been made? It is well recognised that looking back from the outcome makes the assessor susceptible to hindsight bias, which leads to an overestimation of the foreseeability of the outcome (Roese Reference Roese and Vohs 2012 ) and that the resulting investigations can contribute to a culture in which clinicians feel that they are liable to be blamed for unpredictable outcomes (Munro Reference Munro 2019 ). However, more fundamentally, the decision maker is in effect being tested against a standard that is almost impossible to meet. Not only do they not know the outcome, but as articulated above the empirical evidence also suggests that even if they had fully considered the relevant risk factors, that outcome would have been nigh on impossible to predict in an individual case. Another way of illustrating the contradiction is to consider the decision not only in light of actual events but also in the counterfactual scenario in which the outcome did not occur. Concluding that it was reasonable in the latter scenario but not in the former means that the clinician is placed in the unenviable position of being assessed by a standard that is not known at the time of making the decision and only becomes known after a future unlikely and unpredictable outcome has occurred (Bhandari Reference Bhandari, Thomassen and Nathan 2022 ).

What is the relevance of this to practice? At the time of making a critical clinical decision, as well as thinking about the possibility of future harm enacted by the patient, clinicians’ decisions are also influenced by an in-the-moment contemplation of an unfavourable future appraisal of their decision-making in the event of a serious adverse event occurring (even though the event is unlikely) (Nathan Reference Nathan and Wilson 2021a ). The issues can be illustrated by a development of the scenario presented in the vignette above. Although Amy remained of the view that admission was indicated, there had been previous tension between her and the home treatment practitioner and she did not have the confidence to contest the decision to decline admission. She also had on her mind thoughts about a member of her team who was still off work for stress due to the experience of the way she was questioned in both an internal investigation and coroner's inquest in a separate case 6 months before. When Amy told Tom that he had to go home, he abruptly left the hospital. In Amy's clinical entry she justified her decision not to pursue the option of admission by stating that although Tom ‘threatened’ to throw himself off a motorway bridge this appeared to be for ‘secondary gain’ (to secure admission) and she thought that because he was talking about events in the future the risk of suicide was not high. Thus, although in reality clinicians are unable to reliably predict the outcome, they are prone to hold in mind an approach that relies on a deterministic predictive model (in which an outcome is an inevitable result of the antecedent causes), further encouraging the spurious categorisations of patients as high or low risk, the use of such categorisation to allocate resources and the adoption of defensive practices (Munro Reference Munro 2019 ). Amy would, she thought, have felt more able to take a different approach to the dilemma she faced if it was clear to her that in the event of a future untoward incident, the investigation would not use the outcome as a basis for judging her actions and account was taken of the real-time complexity of the situation. She would have felt less motivated to use a spurious risk categorisation to defend herself against what she imagined, from the perspective of a hindsight-armed investigator or coroner, could look like a ‘missed opportunity’. More importantly, by feeling able to acknowledge with Tom (and in her clinical entry) that she remained concerned about the risk, the encounter would have been more validating and there would have been greater opportunity for the collaborative exploration of alternative options to admission, which as noted above may have reduced risk.

Therefore, the issue is not just agreeing how to conceptualise risk assessment, but also agreeing how to conceptualise the system in which the risk assessment activity occurs. Rather than conceptualising a deterministic system (i.e. one in which the future state of every aspect of the system can be described), risk assessment should be characterised as an informed process to reduce uncertainty within a complex system of unknowable future states. More research is needed before firm recommendations can be given about alternative models to learn from adverse incidents, but possible approaches include appraising any decision of interest in light of a counterfactual scenario in which the outcome did not occur, appraising decisions against pre-agreed standards, appraising decisions without knowledge of the outcome and/or focusing on potential latent factors (i.e. systems, processes and training) rather than just linear cause-and-effect ones (Bhandari Reference Bhandari, Thomassen and Nathan 2022 ).

As yet, it has not been possible to produce a method for an individual clinician to accurately predict whether or not the patient they are assessing at a single point in time will go on act in a way that seriously harms themselves or others in the near future. It remains to be determined whether the alternative approach of attempting to apply a quantitative estimate to possible future events has applicability in such a single instance. Given that a person's future behaviour is dependent on the interplay over time between their actions (which are in turn dependent on innumerable and often unknowable mental processes) and the environment in which they will exist (which takes the form of a complex and dynamic system of other unpredictable and interdependent agents), it seems unlikely that accurately foretelling a single person's future will be possible anytime soon. In the meantime, a faith in this possibility can interfere with the goal of risk assessment, which should be to inform clinical decisions with the aim of reducing the likelihood of future serious harm while at the same time improving patient health and well-being. Oversimplified categorical judgements are not just liable to be wrong. The rigid and overconfident adherence to such judgements can also undermine the therapeutic potential of the assessment.

An awareness of the factors that have been found at a group level to be associated with an increased likelihood of harmful events is still important. Armed with such an awareness the clinician can reach an informed conclusion about the type of harm that the risk management plan should address and can engage the patient in a discussion about strategies to address those factors that are modifiable. However, the success of new models of risk assessment will not merely be a function of the components of those models. Attention also needs to be paid to clinician-based and system-based issues that have a bearing on the implementation of the model. If, as the empirical evidence suggests, humans are naturally inclined to categorise and to be subject to unthinking biases in forming judgements about the future, then attention also needs to be given to enhancing the psychological competencies of risk assessors and incident investigators, so that they are more able to resist these inclinations and remain actively open-minded. Furthermore, for as long as the wider system takes a deterministic approach in judging previous decisions in light of an adverse outcome, then clinicians (who, the empirical evidence suggests, have an eye to the anticipated findings of such investigations in their day-to-day practice) will find it difficult to lose faith in the deterministically informed assumption that the future can be read. Developing, implementing and researching risk assessment requires clarity about the goal of this clinical activity, its meaning in real-world settings (which should take into account the wider system as well as the individual clinical encounter) and the human factors that can interfere with the achievement of the goal.

R.N. conceived the article and was responsible for the figure and table. R.N. and S.B. reviewed the relevant literature and drafted and edited the manuscript.

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Select the single best option for each question stem

a frequentist probability is the long-run frequency over a large number of repetitions of an experiment

b classic probability is the fraction of the total number of possibilities of different likelihoods in which the event occurs

c classic probability is directly relevant to clinical risk assessments

d the term ‘uncertainty’ applies when the probability distribution of the outcome is known

e subjective probability is equivalent to propensity.

a risk assessment should not be seen as a stand-alone clinical activity

b a phenomenological approach is likely to produce a more case-specific understanding than a diagnostic approach

c risk factors should be understood in the context of the person's current experiences

d it is good practice to seek information from a range of sources

e all suicidal ideation can be defined as either passive or active.

a the use of risk assessment tools enables clinicians to predict future violent and suicidal acts

b the idea of risk assessment as prediction is fallacy

c risk factors tend to occur very rarely in clinical practice

d serious harm outcomes are common in psychiatric practice

e risk categorisation is unlikely to be harmful.

a the availability heuristic refers to the influence on probability judgements of the readiness with which relevant examples come to mind

b affective processes within the assessor may influence the perception of risk

c assessors should ignore their own potential biases when undertaking risk assessments

d active open-mindedness is associated with better judgements about future events

e assessors’ willingness to accept the role of change is associated with better judgements about future events.

a hindsight bias refers to the tendency to retrospectively underestimate the foreseeability of a known outcome

b concluding that a decision was incorrect in light of the actual adverse outcome but would have been correct if that outcome had not occurred is a good way of testing clinical decision-making

c deterministically judging clinical decisions in the knowledge of the outcome generally proves helpful in learning from adverse outcomes

d when making decisions in acute psychiatric scenarios, clinicians are liable to contemplate an unfavourable appraisal of their decisions in the event of an adverse outcome

e risk assessment in practice should depend on a deterministic conceptualisation of reality.

MCQ answers

1 a c 2 e c 3 b c 4 c 5 d

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• Volume 30, Issue 1
• Rajan Nathan (a1) and Sahil Bhandari (a2)
• DOI: https://doi.org/10.1192/bja.2022.67

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12 Risk assessment

• Published: June 2018
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General adult nurses work with people in hospitals, hospices, community care services, and people’s homes. Irrespective of the place of work, there will be many routine procedures which are an important part of reducing risk to people and organizing subsequent nursing work. It is recognized that all organizations will have different risk assessment tools and recording procedures, but there are generic principles of safety which underpin all these tools. An important aspect of nursing decision-making and practice is understanding and managing risk, and factoring risk management into the planning and delivery of nursing care. This chapter considers the broad principles of risk assessments which are widely used across healthcare environments.

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Patient Safety and Managing Risk in Nursing

• Melanie Fisher - Northumbria University, UK
• Margaret Scott - Northumbria University, UK
• Description

Patient safety is a predominant feature of quality healthcare and something that every patient has the right to expect.  As a nurse, you must consider the safety of the patient as paramount in every aspect of your role; and it is now an increasingly important topic in pre-registration nursing programmes. This book aims to provide you with a greater understanding of how to manage patient safety and risk in your practice. The book focuses on the essentials that you need to know, and therefore provides a clear pathway through what can sometimes seem an overwhelmingly complex mass of rules, procedures and possible options.

Key features:

·         A practical introduction to patient safety and risk management written specifically for nurses and nursing students

·         Case studies and scenarios help you to apply patient safety and risk management principles to actual practice

·         Each chapter is mapped to the relevant NMC standards and Essential Skills Clusters so that you can see how you are meeting the professional requirements

·         Activities throughout help you to think critically and reflect on practice.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

SAGE 2455 Teller Road Thousand Oaks, CA 91320 www.sagepub.com

this book is essential for novice nurses and provides a good understanding of how to manage patient safety and risk in clinical practice, easy to read and relates extensively to the governing bodies.

Another excellent book from the Transforming Nursing Practice series. Well laid out, easy to read and full of helpful activities that are relevant to practice and assist in helping students to understand and apply the risk management principles to their own practice

A helpful, informative text . The text will help students to explore the role of the professional nurse in terms of managing risk in clinical practice. Issues of communication, assessment, Human factors and quality of care have been covered. The information is presented in a clear , logical and visually appealing way. I would recommend this book to all my students.

An useful review of several topics relevant to patient safety with application to nursing. I thought the interactive activities were very helpful.

useful for all types of health care professions

This book is succinct and full of key information. I deem it vital for our Quality and Safety Module.

Recommended this textfor students inthe thrid year working on preesebtaion based on this risk managing...

Easy to read and the content is very relevant for health and social care students

This book is very useful and I found it helpful for my students, accordingly, I put it in the course syllabus as a supplementary material to be used by the students because it covers some of the items in the course contents. the students were advised to buy the book as supplemental to the required textbook. thank you

A good introduction to patient safety.

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For instructors, select a purchasing option, related products.

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Being prepared for an emergency or a large scale disaster begins with the intent to prevent or reduce the negative impacts of risk scenarios. Therefore, we should start by discussing risk management to provide a foundation for the later sections on emergency planning, preparedness, response and recovery.

Please start reviewing the following definitions cited in the Emergency Management Planning Guide (Government of Canada 2010-2011).

A hazard is a potentially damaging physical event, phenomenon or human activity that may cause the loss of life or injury, property damage, social and economic disruption or environmental degradation. ( An Emergency Management Framework for Canada . Public Safety Canada)

The combination of the likelihood and the consequence of a specified hazard being realized; refers to the vulnerability, proximity or exposure to hazards, which affects the likelihood of adverse impact. ( An Emergency Management Framework for Canada . Public Safety Canada).

Risk assessment

A process that involves information collection and in which values to risks are assigned for the purpose of informing priorities, developing, or comparing courses of action, and informing decision making. ( DHS Risk Lexicon . Department of Homeland Security).

Risk management

The use of policies, practices and resources to analyze, assess and control risks to health, safety, environment and the economy. ( An Emergency Management Frameworks for Canada . Public Safety Canada).

In summary, a hazard is a potentially damaging event while “risk” reflects the combination of the likelihood and the consequence when that hazard occurs. Risk management is the process that includes, risk identification, risk assessment, risk mitigation plans, and evaluation.

Risk assessment often employs a tool referred to as a risk matrix that compares the likelihood and consequence of different risks.  The value of using an assessment tool, such as a risk matrix, is that it can help focus efforts to reduce or mitigate the risk if it cannot be eliminated.

Activity #1

Watch this video from Public Health which introduces the concept of how to use a risk matrix.

Video: Risk and How to use a Risk Matrix (5:28)

A risk matrix tool can be used in planning for emergencies or disasters, for example, rating the likelihood and consequences of various pandemic hazards such as staff sick calls, supply chain disruptions (PPE for example), negative pressure room access and so on. An organization may determine, through the risk matrix, that its highest risk is staffing shortage. Then significant focus on mitigation plans for staffing shortage would be developed to manage that risk.

Once the steps of hazard identification and risk assessment have been completed, then the next step is to work to mitigate the hazards that pose the most pressing or concerning risks. These mitigation plans are “control measures” implemented to control or at least reduce the likelihood of harm reaching the individual.

The matrix concept is also used to compare how well controls or mitigations can reduce the risk.  For example, risk matrix assessments are often applied to occupational health and safety situations. In assessing the likelihood, the question should be asked “If the hazard occurs, how likely is it that the worker will be injured. This should not be confused with how likely the hazard is to occur.  Using a pandemic example, the hazard is exposure to the virus. The likelihood of staff injury (illness) is unlikely or highly unlikely If the staff member was always a safe distance from a COVID positive patient AND was consistently wearing appropriate PPE. In terms of consequences, adding vaccines for the staff in appropriate PPE, reduces the potential injury level.  The matrix helps evaluate the impact of the mitigation measures (distance, PPE and vaccine).

Mitigation of the risk can be addressed at various layers of intensity, the highest level of intensity being total elimination of the risk. Because it is not always possible to eliminate risk totally, other mitigations are used to reduce the risk to the extent possible or feasible. Below is a graphic of the  Hierarchy of Controls used by the Canadian Centre for Occupational Health and Safety (CCOHS)  that can help shape the process of formulating your organization’s control measures. It is also used by the American agency National Institute for Occupational Safety and Health (NIOSH).

• Elimination is the most effective control. If it is possible to physically remove a hazard, it must be done.
• Substitution is the second most effective control. It proposes the replacement of the hazard with a safer alternative e.g. automating a manual process identified to be dangerous, buying a newer equipment model with better safety ratings, etc.
• Engineering controls refer to physically isolating people from the hazard if at all possible
• Administrative controls refer to changing the way people work. This may include procedural updates, additional training, or increasing the visibility of precautionary signs and warning labels.
• PPE is the last line of defense if workers cannot be completely removed from a hazardous environment.

In the healthcare environment, the hierarchy of controls is often used in risk management activities related to improving patient safety. For example: Elimination controls have been used to reduce harm from high concentration drugs being administered inadvertently.  Substitution controls have included the implementation of pressure reduction mattresses to reduce pressure injuries. Engineering controls have been used in “Smart Pumps” to create hard limits on high-risk IV infusions. Administrative controls include policies, protocols, or ‘behaviour’ requirements such as face-to-face shift hand-off reports.

Mitigation of potential risks can be undertaken in response to an incident or event but is ideally undertaken proactively through planning. The proactive approach is important for prevention and is, therefore, a key tool in patient safety. In fact, Accreditation Canada requires an organization to undertake such proactive risk management activities. One standardized approach to proactive risk mitigation is through a process called Failure Modes and Effect- Analysis (FMEA).

Activity #2

Learn about Failure Modes and Effect Analyses (FMEA) as a framework for proactive risk management.

Video: An Overview of the Failure Modes and Effects Analysis (FMEA) Tool (2:19)

 Activity #3

• Failure Modes and Effects Analysis (FMEA) Tool
• Using ISMP Canada’s Framework for Failure Mode and Effects Analysis: A Tale of Two FMEAS    
• Canadian Centre for Occupational Health and Safety (CCOHS) 
• Emergency Management Planning Guide (Government of Canada 2010-2011)

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Leadership for Nurses in Clinical Settings Copyright © 2022 by Dr. Kirsten Woodend, Dr. Catherine Thibeault, Dr. Manon Lemonde, Dr. Janet McCabe is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Spotlight on risk assessments

RCN safety rep Neil Thompson explains why risk assessments are so important and what members should do if they think one is needed

When should risk assessments be carried out.

Pretty much everything in the workplace requires a risk assessment. From using a computer to handling hazardous goods or receiving a new piece of equipment, it’s essential that a risk assessment is carried out and counter measures are put in place to ensure the safety and wellbeing of everyone. 

Employers are required to carry out risk assessments of the work environment and work activities. These should be reviewed regularly, especially if there have been any changes or incidents have taken place. 

In an ideal world, where the workplace also has sufficient people with time release to carry out health and safety duties, there would be a much more regular programme of risk assessment in place.

Why are they so important?

If an effective risk assessment hasn’t been carried out, how can the employer know that what you’re doing is safe for you, your colleagues and your patients? Risk assessments and risk management save lives.

How are risk assessments linked to the safety rep role?

Safety reps work in partnership with management and employers to ensure that risk assessments are not only carried out but acted upon. We can also identify areas where risk assessments are required, escalate concerns if adequate measures aren’t put in place, and act as a voice for other members.

Do you have any advice on effectively carrying out risk assessments?

It is an employer’s responsibility to make sure that risk assessments are carried out but sometimes safety reps may want to use one to build a case for improvements or highlight what action needs to be taken to protect members. 

Make sure they are methodical, consistent and that you use an official form. Your employer should be able to provide one, or you can find templates online on the Health and Safety Executive website.

I’d also advise taking photos if possible – of things, never patients or people – to build up a strong body of evidence should any further action be required. But my main piece of advice would be to work together with your managers, both for the initial risk assessment and moving forwards. This is the most effective way to ensure things get done.

What should members do if they think a risk assessment is required?

The first thing they should do is submit an incident report. Then they should talk to their manager or their local safety rep to let them know and to make sure it’s followed up.

It’s always worth keeping an eye on it yourself and checking what progress is being made.

If for any reason, someone feels it isn’t being taken seriously or escalated appropriately, they can always talk to the next level of management or, if they work in the NHS in England, a Freedom to Speak Up Guardian. 

Find out more

Visit the Health and Safety Executive’s website for more information.

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A Comprehensive Guide to Risk Management in Skilled Nursing Facilities

In the rapidly evolving healthcare landscape, the safety and well-being of patients in skilled nursing facilities (SNFs) remain a paramount concern. Effective risk management in healthcare is not only about mitigating liabilities; it’s about ensuring patient care, financial stability, and regulatory compliance. This guide delves into the complexities of risk management within SNFs, from its importance to proactive strategies that enhance patient safety and elevate the quality of care.

Understanding Risk Management: Safeguarding Patients and Facilities

Risk management is a systematic approach to identifying, assessing, and mitigating potential risks that could impact an organization’s operations, reputation, and, most importantly, patient health. For SNFs, risk management transcends mere procedures—a commitment to delivering exceptional care while preparing for unforeseen challenges.

Navigating the Complexities of Healthcare Risks

The healthcare sector is replete with multifaceted risks that extend beyond medical diagnoses. Data breaches, regulatory non-compliance, medical errors, and staff shortages can trigger far-reaching consequences.

SNFs, entrusted with vulnerable residents face amplified risks due to diverse health conditions. The role of healthcare risk management in SNFs goes beyond fiscal prudence—a cornerstone of ethical caregiving.

Spotlight on Key Aspects of SNF Risk Management

SNFs operate in a world of varied risks, ranging from slip and fall injuries to medication errors, neglect, abuse, choking hazards, malnutrition, dehydration, and elopement.

The challenge is exacerbated by staffing shortages, placing caregivers under immense responsibility. While skilled nursing home insurance offers support, it’s no substitute for strategic healthcare risk management plans and strategies proactively tackling these challenges.

Proactive Strategies to Enhance Patient Safety

Effective risk management is about prevention, not reaction. For SNFs means implementing strategies that prioritize patient safety and optimize operations.

Assessing patient rooms and common areas for slip and fall risks, adopting sophisticated medication cross-checking systems, addressing elopement risks, and providing ongoing safety training for caregivers are cornerstones of proactive risk management.

These strategies protect patients and alleviate financial burdens linked to medical errors.

Navigating Risks During Emergencies

Emergencies, whether pandemics or natural disasters pose unique risks to SNFs. A robust risk management plan anticipates these challenges.

For instance, during the COVID-19 pandemic, SNFs with comprehensive pandemic plans responded effectively. Emergency response agreements safeguard patient care by minimizing evacuation needs and reducing financial and emotional stress.

Power of Collaboration and Unconventional Mutual Aid

In facing risks, the collective strength of healthcare providers shines. Unconventional mutual aid systems foster collaboration and support during emergencies.

These agreements facilitate seamless patient relocation, matching medical and mobility needs while upholding safety standards. The result is a united front that mitigates risks and ensures healthcare continuity even during crises.

Executing Effective Risk Assessments

Central to successful risk management is a comprehensive risk assessment. By asking key questions about hazard likelihood, potential impacts, prevention strategies, and patient safety concerns, SNFs can pinpoint vulnerabilities and tailor risk management plans. Aligning with regulatory guidelines guarantees adherence to best risk management practices.

From Plan to Practice: A Journey of Ongoing Improvement

A well-crafted risk management plan is a living document adapting to evolving risks and regulations. Monitoring and periodic adjustments ensure SNFs remain agile and prepared.

Ongoing risk manager development and compliance with mandates bolster SNFs against uncertainties.

Embracing the Imperative of Risk Management

Risk management is more than a requirement—it’s a commitment woven into the core of responsible SNFs. Beyond compliance, it signifies dedication to patient safety, financial resilience, and exceptional care.

By internalizing risk management’s significance, SNF managers empower teams to adopt proactive strategies that protect patients and uphold organizational integrity.

Through collaboration, meticulous assessment, and unwavering vigilance, SNFs transcend complexities, reduce liabilities, and make healthcare organizations fulfill their ethical duty to prioritize patient safety. As SNF managers champion these principles, they steer their organizations toward a safer, more secure healthcare future.

Guiding SNF Managers Towards a Safer Future

In the dynamic healthcare landscape, risk management is a continuous journey. For SNF and healthcare risk managers everywhere, it’s about minimizing liabilities and maximizing patient well-being. As risks evolve, SNFs must remain adaptable and forward-thinking, embracing innovative solutions and collaborative approaches.

Leveraging Technological Advancements

Technology is a powerful ally in risk management in today’s digital era. Advanced electronic health record systems enhance medication safety, while automated monitoring systems detect potential hazards efficiently. Embracing innovation bolsters patient safety and positions SNFs as pioneers in the healthcare industry.

Educational Empowerment for All Stakeholders

Effective healthcare risk management extends beyond administrators and caregivers—it encompasses every member of the SNF community. Educational initiatives that raise risk awareness and impart response strategies create a culture of vigilance. Empowered stakeholders serve as an extra defense against potential risks, strengthening patient safety and organizational resilience.

A Call to Action: Holistic Risk Management

As SNF managers navigate risk management, a holistic approach emerges as the guiding principle. By embracing a comprehensive risk management plan spanning patient care, financial stability, regulatory compliance, and emergency preparedness, SNFs fortify their foundations.

This approach ensures no facet of medical risk management is overlooked, elevating care standards and safeguarding against unforeseen challenges.

Addressing Patient-Care Risks in Nursing Homes

Expanding long-term healthcare facilities, such as nursing homes and memory care centers, reflect the growing need to care for aging populations. These facilities play a crucial role in providing compassionate care but also face inherent risks.

This guide outlines the common risks associated with patient care in nursing homes, emphasizing the importance of using risk management programs and skilled nursing home insurance to ensure the safety of residents.

The Impact of Care Risks in Nursing Homes

Nursing homes and other residential care facilities cater to vulnerable individuals, including seniors with underlying health conditions. This demographic faces elevated risks due to operational hazards within the facilities.

Such injuries and illnesses lead to soaring expenses for the facilities and residents. The increase in expenses includes rising premiums for skilled nursing home insurance, contributing to higher overhead costs.

Patient Risks: An Overview

Aging individuals residing in nursing homes encounter various risks, including:

• Slip and Fall Injuries: Loose flooring, uneven walkways, and moisture.
• Medication Errors: Involving approximately 27% of facility residents on average, leading to severe consequences.
• Neglect or Negligence: Stemming from staffing shortages and high workloads.
• Bedsores: Resulting from inadequate patient care.
• Abuse by Caregivers or Fellow Residents: Representing a significant concern.
• Choking Hazards: Affecting elderly individuals with specific dietary needs.
• Malnutrition and Dehydration: Common issues that can arise.
• Elopement: Affecting residents with cognitive declines, such as dementia.

Improving Patient Safety: A Top-Down Approach

By adopting a safety-focused approach, SNFs can significantly reduce or eliminate many risks.

This starts with stakeholders identifying common risk exposures and implementing mitigation plans. These efforts complement the protection offered by skilled nursing home insurance, ultimately benefiting caregivers and residents. Critical risk-reduction practices include:

• Slip and Fall Prevention: Assessing areas for hazards, like slippery flooring, uneven surfaces, and tripping risks.
• Medication Management: Implementing cross-checking systems to prevent errors and improve patient safety.
• Elopement Prevention: Installing automatic door locks, video monitoring, and regular patient checks for residents prone to wandering.
• Training: Ensuring caregivers receive ongoing safety training covering risk mitigation, patient care, abuse/neglect identification, and handling techniques.
• Insurance Evaluation: Regularly review skilled nursing home insurance policies to ensure they align with facility risk exposures.

In Conclusion: A Safer Tomorrow Through Effective Risk Management

Risk management is more than a procedural checklist—it’s a pledge to protect lives, uphold integrity, and embrace innovation. For SNF managers, the journey involves more than risk avoidance; it’s about fostering a culture of safety and excellence.

By staying attuned to emerging risks, leveraging technology, and educating all stakeholders, SNFs shape a future where patient, health care, and safety are unwavering priorities. In the face of uncertainty, SNF managers can lead their organizations toward a safer and more secure tomorrow.

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Transforming Risk Management in Healthcare: A Leap Towards Automated Solutions

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Suicide risk assessment and prevention

Smith, Erin Murphy MSN, RN

Erin Murphy Smith is an assistant professor of nursing at the Kingsborough Community College of the City University of New York in Brooklyn, N.Y. She's also an assistant director of nursing at a Level I trauma center in New York City.

The author and planners have disclosed no potential conflicts of interest, financial or otherwise.

For more than 135 additional continuing-education articles related to management topics, go to NursingCenter.com/CE .

Earn CE credit online: Go to http://nursing.ceconnection.com and receive a certificate within minutes .

Review concrete steps that you and your staff members can take to diminish the risk of patient suicide attempts.

Patient safety remains a central concern of nurse managers in every healthcare setting. Although the welfare of patients encompasses a broad range of concerns, the increasing prevalence of suicide in our society compels nurse managers to ensure a safe healthcare environment for patients with suicidal ideation. These efforts include the elimination or, at least, the mitigation of physical setting characteristics that enable suicide attempts. Equally, nurse managers need to ensure that the nursing team is adequately trained to assess patient suicide risk and take appropriate follow-up prevention steps.

This article reviews the statistical impact of suicide, as well as concrete steps that nurse managers and nurses can take to diminish the risk of patient suicide attempts.

A growing concern

As a nurse manager, your duties include, but aren't limited to, interviewing and hiring nursing staff, collaborating with medical staff, developing budgets, interacting with patients and families, scheduling, professional development, and staff evaluation. Although you may have included the possibility of patient suicide within these concerns, the scope of nursing's responsibility to prevent suicide attempts has ballooned commensurate with the increasing prevalence of such events.

Suicide is the 10th-leading cause of death in the US; suicide rates have increased approximately 30% since 1999. 1,2 The CDC reported that 45,000 individuals died by suicide in the US in 2016. 2 Beyond the financial and staffing ramifications posed by escalating suicide rates, the complexity of the contributing factors of suicidal ideation make the nurse manager's job all the more essential to the mitigation of patient suicide attempts. In recognition of the growing magnitude and difficulty of this problem, the National Action Alliance for Suicide Prevention and the American Foundation for Suicide Prevention established a goal of reducing the annual suicide rate by 20% by 2025. 2

The American Psychiatric Association estimate that 1,500 suicides take place on inpatient hospital units in the US each year. 3 In 2007, The Joint Commission established the National Patient Safety Goal (NPSG) 15.01.01 to focus healthcare organizations on averting suicide. However, in view of the 85 suicides reported as sentinel events over the last 5 years, The Joint Commission is seeking to further enhance preventive efforts. 1

Scenarios reflecting the nature of suicide in the healthcare setting highlight the relevance of these statistics to nurse managers and clinicians. In one case, a 50-year-old critical care nurse with 24 years' experience committed suicide after she was fired for a self-reported medication error that may have contributed to the death of a baby with severe heart problems. 4 (See At risk: Nurses .) In another hospital, personnel brought a 40-year-old ED patient who was admitted for suicidal ideation to the radiology unit for tests. The patient found his way to the roof of the building and jumped after being left alone in the radiology waiting area. In yet another facility, a patient asked to be voluntarily admitted after a suicide attempt and changed into a hospital gown. After she waited alone in an exam room for more than an hour, the patient walked past the ED charge and triage nurses' stations, as well as multiple other hospital personnel, and eloped. She walked to a nearby highway where she was killed by a passing vehicle.

These cases represent a small sampling of a complex and growing healthcare crisis that nurse managers must be ready to contend with on any given day. Moreover, this isn't just a behavioral health unit problem. Suicide is an issue that cuts across all clinical practice settings, so nurses working on every unit in a hospital must be ready to assess for suicide risk and know what to do if a patient exhibits suicidal ideation.

The American Psychiatric Nurses Association (APNA) indicates that the role of the nurse in preventing suicide includes both system- and patient-level interventions. In essence, a nurse manager “maintains environmental safety; develops protocols, policies, and practices consistent with zero suicide; and participates in training for all milieu staff.” 5 Nurse managers must also ensure that staff members demonstrate an understanding of the statistics, epidemiology, risk factors, and protective factors related to suicide as an essential nursing competency for suicide risk assessment and prevention. In this sense, one study observed, “risk management is the cornerstone of nursing care.” 6

It can happen on your shift

Globally, one suicide occurs every 40 seconds, according to the World Health Organization. 7 In the US, suicide exceeds motor vehicle fatalities and claims more than twice the number of lives from homicides. Although American suicide rates had been stable or falling in the second half of the 20th century, the CDC determined that suicide was the second-leading cause of death for individuals between ages 10 and 34 in 2014. 8

Amplifying the impact of these distressing statistics, there were 20 attempted suicides for each completed suicide. Experts have concluded that these data demonstrate a pervasive sense of desperation coursing through American society, making it all the more important that we understand this societal trend and sharpen our skills to contend with its manifestations in the healthcare setting. 9

Additionally, nurses should be aware that the surge in suicides, although widespread, may place different demographic groups within divergent risk categories. For instance, the CDC has reported that:

• Although the age-adjusted suicide rate for men (20.7) was three times greater than women (5.8), the percentage increase in suicide rates from 1999 to 2014 was greater for women (45%) than for men (16%).
• The highest increase in suicide rates was girls age 10 to 14 (200%).
• Suicide rates for women age 46 to 64 increased 63%, whereas the rates for men of the same age group increased by 43%.
• American Indians experienced the steepest rise in suicide among all racial and ethnic categories (89% for women and 38% for men).
• Suicide rates for Black men declined by 8%. 8

Just as nurses consider demographic data in their patient assessments, these data must be weighed as part of a suicide risk assessment.

Key risk factors

Suicide is a complex phenomenon. In addition to demography, risk factors may include an intricate amalgam of psychological, social, biological, cultural, and environmental circumstances. Nurse managers should ensure that their nurses are knowledgeable about the variety of risk factors that may come to light in a patient history. Specifically, recent research demonstrates that nurses should note and assess patient histories that reveal the following risk factors for suicide: 10

• mental or emotional disorders
• past suicide attempts or self-inflicted injury
• physical pain or impairment
• substance abuse
• impulsivity following a life crisis
• conflict-related stress
• victim of violence or abuse
• discrimination based on race, ethnicity, gender identity, or sexual orientation
• pattern of aggressive or antisocial behavior
• imprisonment.

Nurses should be cognizant of the potential methods of suicide. In particular, a patient's ready access to weapons or other means of self-violence, together with suicidal thoughts, may raise the suicide risk assessment for that patient. For instance, the CDC indicated that men use firearms in 55.4% of suicides, whereas women most often used poisoning (34.1%). 8 Certain state laws may impose a legal duty on medical personnel to inform designated authorities that a mental health patient may have weapons in the home. 11 Another study found that suicide via suffocation in the US increased by 45.7% from 2005 to 2014. Many objects commonly found in the healthcare environment may be employed in this suicide method.

Although easy availability of weapons, poisons, and so on should be factored into the nursing assessment, the lack of any apparent access isn't reason to discount the patient's risk of suicide.

Nurses should also be aware that patients' culture and spirituality are relevant components of a patient assessment. In particular, research demonstrates that religious faith may be relevant when assessing for suicide risk. Studies on the association between religious observance and suicide reflect the complexities of assessment and prevention. Many cross-sectional studies have demonstrated that religion provides a protective factor against completed suicide. The Nurses' Health Study found that religious attendance once or more per week was associated with an approximately fivefold lower rate of suicide compared with never attending religious services. However, at the clinical level, confounding factors may make the usefulness of religious observance as a factor in assessing patients for suicide risk more problematic. For example, although the condemnation of suicide by most organized religions may help protect against suicide (among other reasons), other religious doctrines, such as condemnation of lesbian, gay, bisexual, and transgender (LGBT) individuals, may nullify that benefit for certain patients. 13 (See At risk: LGBT individuals .)

Nursing skills needed

Failure to maintain nursing competence in suicide assessment can have devastating effects not only for our patients and their families, but also for the care providers who become secondary victims. 4 According to The Joint Commission, 14.25% of suicides occur within a hospital but outside of its behavioral health unit. The Joint Commission also found that over 1,000 suicides from 2010 to 2014 occurred within 72 of hours of discharge from an around-the-clock healthcare setting such as the ED. 14 Any nurse involved in patient care must be attentive to suicide risk factors and stay informed on the most effective prevention strategies.

Unfortunately, nursing scholarship and clinical training in this area have lagged behind other healthcare providers. For example, one study determined that nursing suicide assessments relied on important but incomplete factors of intuition, experience, and the assessments of others. 10 Another researcher identified that nurses' psychological factors, such as emotions and unresolved grief, complicated their assessment and treatment of suicidal patients. This study also found that nurses sometimes exhibited confusion and misconceptions about suicide, such as expressing that it was a “coward's way out.” Most important, the study highlighted nurses' ambivalence about their qualifications to interact with patients at risk for suicide. 15

A more recent comprehensive review of the literature on nursing suicide assessments found that most RNs lack the skills to effectively evaluate, treat, or refer a suicidal patient. The authors called for improved research, education, and the implementation of evidence-based clinical care practices and standards. 16

Both The Joint Commission and the APNA have proposed such evidence-based standards. 5,17 The following is a summary of these guidelines.

• Review each patient's personal and family history for suicide risk factors . Employ effective therapeutic communication techniques. This includes direct questioning during the assessment. For instance, nurses should ask: 18
• —“Have you ever thought of hurting yourself?”
• —“Have you ever tried to hurt yourself in the past?”
• —“Have you ever contemplated suicide?”
• —“Do you have a plan about how to end your life or hurt yourself?”
• The severity of suicidal ideation may be assessed with questions such as:
• —“How often do you have thoughts of suicide?”
• —“Have these thoughts become more frequent?”
• Screen all patients for suicide ideation upon admission using a brief, standardized questionnaire . 18 Review and assess the questionnaire before discharge.
• Begin 1:1 observation of patients at acute risk for suicide . Once 1:1 monitoring is initiated, the nurse should explain to the patient that constant observation is for his or her safety and isn't in any way punitive. The staff member must face and be within arms-length of the patient at all times. Although it may seem self-evident that the patient must never be left alone, even while using the bathroom or shower, this still must be stressed to the staff member. The nurse responsible for this patient must remain vigilant and ensure that the staff member maintains the patient's safety at all times. As a matter of standard practice, the nurse will apprise the nurse manager of the patient's risk of suicide and the steps commenced to mitigate the risk. The psychiatrist is responsible for discontinuance of constant observation.
• Obtain an immediate psychiatric consult for acute risk patients . Arrange for such a consult within 1 week of discharge for lower risk patients. Patients at low risk for suicide demonstrate no intent to act on their thoughts of self-harm. The psychiatrist will determine if the patient is at low risk for suicide based on all relevant and available evidence.
• Give every patient with suicidal ideation the National Suicide Prevention Lifeline phone number: 1-800-273-TALK (8255) . This organization also has online chat access at suicidepreventionlifeline.org . Additionally, the National Institute of Mental Health has concluded that online and social media interventions can safely enhance feelings of interconnectedness in young people at risk for suicide, but also notes the need for further studies to substantiate the effectiveness of these interventions. One example of such an online resource is the Trevor Project at www.thetrevorproject.org , which specializes in at risk LGBT youth.
• Identify coping strategies with the patient . Some of these strategies include:
• —suggest distractions, such as talking on the phone, reading a book, or going to the movies
• —encourage the formulation of a crisis management plan
• —instill hope
• —draw on coping experiences successfully employed in the patient's past.
• Discuss ways of restricting access to lethal means . Understand any state or local legal requirements regarding access to firearms if it's determined that the patient may be a risk for self-harm or harm to others.
• Maintain a collaborative relationship with the patient . Constantly strive to establish a relationship of trust. Without trust, there can be no effective communication. Without communication, there can be no effective care.
• Accurately communicate the patient's risk to the treatment team and other appropriate personnel . Specifically, the APNA calls for nurses to assess patients for risk and protective factors and report that information and evaluation to the healthcare team.
• Assess and modify the environment to maximize patient safety . For instance, lanyards, call bell cords, I.V. tubing, plastic bags, razors, belts, shoelaces, and sharps should be removed from the patient's environment to a degree appropriate for the risk.
• Accurately document risks and actions taken in response . Documentation is essential for transitioning the patient from one unit or shift to another. 19

The Joint Commission recommendations

The Joint Commission convened two meetings of suicide prevention experts in the summer of 2017. This panel developed recommendations for the prevention of suicide within inpatient psychiatric units, as well as general acute inpatient settings. These recommendations focus on the steps that hospitals need to take to eliminate or mitigate serious environmental hazards. 1

The Joint Commission concentrated on the presence of ligatures that may be employed for self-harm. Ligatures in the healthcare setting include I.V. lines, call bell cords, and window treatment cords. In addition, ligature anchor points must be considered as a potential risk for a patient with suicidal ideation. Ligature points are anchors that may be used to bear weight, including: 1

• door locking mechanisms
• dropped ceiling structures
• shower and other bathroom fixtures
• exposed pipes
• wall-mounted items such as soap dispensers
• I.V. poles and monitors
• patient clothing.

The Joint Commission recommends that the following areas in general acute care settings be ligature resistant: 1

• patient rooms
• patient bathrooms
• transition zones between patient rooms and patient bathrooms
• common patient areas.

Patient medical needs and suicide prevention must be balanced to determine optimal bed assignment. The Joint Commission recommends that if a patient with serious suicidal ideation is admitted, all objects that pose a risk for self-harm that can be removed without adverse events should be removed. There must be mitigation plans and safety precautions in place for patients who require beds with ligature points, such as 1:1 monitoring, assessment of objects brought into the patient's room by visitors, and protocols for patient transport to other part of the hospital. 1

Hospitals must demonstrate that the following are done “routinely and rigorously” for patients with serious suicidal ideations: 1

• training and testing staff on suicide
• implementing 1:1 monitoring
• assessing objects that pose a risk
• removing items that pose a risk
• monitoring visitors
• monitoring bathroom use
• implementing transport protocols.

In the ED, The Joint Commission recommends one of two strategies for suicidal patients: Place the patient in a “safe room” that's ligature resistant or can be made ligature resistant or keep the patient in the main area of the ED while initiating 1:1 monitoring and removing objects that pose a risk for self-harm that can be removed without adverse medical consequences. 1

The Joint Commission states that healthcare organizations should do the following to protect patients in the ED: 1

• screen for suicidal ideation
• assess risk of a suicide attempt
• assess risk of objects in patient vicinity
• remove objects that pose a risk
• initiate protocols for monitoring and patient transport
• train and test staff on suicide.

Veterans Affairs checklist

Studies demonstrate that regular active duty military service members and veterans diagnosed with some mental disorders are at a higher risk for suicide than the population at large. 20 (See At risk: Veterans .) In 2006, the US Department of Veterans Affairs (VA) developed a checklist to identify environmental hazards on acute mental health units treating suicidal patients. The VA implemented the Mental Health Environment of Care Checklist in 2007. 21

The multidisciplinary inspection team that performed quarterly reviews of each hospital's mental health unit under this program included both psychiatric and nonpsychiatric unit nurse managers. The team used the checklist to assess patient safety by identifying the types and location of each hazard. Nationwide, VA facilities identified 7,642 hazards. Analysis of the findings identified a positive correlation between the facility's age and the number of hazards identified. Ligature anchor points were the most common and dangerous hazard identified. However, suffocation risks from plastic trashcan liners and poisoning risks from cleaning products were also significant findings. The program also identified materials that could be used as weapons and called for careful review of dresser drawers, moldings, flatware, chairs, artwork, and small objects. Security issues such as elopement constituted an additional common hazard. Researchers who reviewed the findings of this program noted the importance of ongoing staff training to eliminate hazards. 21

Investigators noted that the checklist has limited usefulness for general medical units because it's nearly impossible to eliminate the hazards identified and continue to treat patients. In this regard, they recommended the use of 1:1 observation for patients with suicidal ideation. A follow-up study determined that the checklist resulted in an 82% drop in suicides in VA facilities (4.2 out of 100,000 admissions to 0.74 out of 100,000 admissions). 22

Connect, communicate, care

Nurse managers play a valuable role in reducing suicide and suicide attempts in the healthcare setting. We can accomplish this not only by ensuring adequate training of the nursing team, but also contributing to changes to the patient environment. Although no single method can be expected to significantly diminish the risk of suicide or suicide attempts, we can implement a broad spectrum of tactics to help alleviate this growing problem. 23

Advances in research will be essential in the development of effective treatment strategies. To this end, the National Institute of Mental Health has launched a 5-year study to test treatments intended to prevent suicide. 24 In addition, the continuing education of experienced nurses in the healthcare setting, as well as the curricula for nursing students, must ensure that nurses are equipped with the skills needed to effectively assess and care for patients who may be at risk for suicide. As the International Association for Suicide Prevention advises, we must “connect, communicate, and care” for our at-risk patients to curtail this societal crisis. 7

At risk: Nurses

Nursing is a caring profession but, all too often, we don't adequately care for our fellow professionals or ourselves. We all deal with the stress of insufficient staffing and shift work, and the emotional rollercoaster associated with patient care. On top of this, researchers have confirmed what most of us know all too well: Nurses at all levels of the profession are often subject to bullying, harassment, and incivility on the job. 1 These stress factors can take a toll. Specifically, nurses may encounter the devastating impact of suicide in both their work and personal lives. One study found that following a patient suicide, nurses experienced shock, condemnation, and fear of reprisal. So, it isn't surprising that nurses are at an elevated risk for suicide. In particular, female nurses are four times more likely to commit suicide than the average woman. 2

Researchers examining suicide rates among the large, long-term cohort of the Nurses' Health Study found an almost five-fold increase in suicide risk among female nurses in the high stress category. As for those nurses reporting minimal stress, researchers concluded that their excess risk of suicide may reflect denial, undiagnosed depression, or an association with other unmeasured risk factors. 3 Another study found that nurses of both sexes had higher rates of suicide than other educated professionals. 4

Simply put, we must do a better job of caring for each other and ourselves. In particular, nurses understand the stress of their coworkers and are well situated to assess when everyday workplace pressure may interact with extraordinary personal or professional trauma or grief to elevate that nurse's risk of suicide. Moreover, nurses can serve as models for coworkers and patients by obtaining help when we feel about to “go over the edge.” Open discussion of these pressures and constructive means to alleviate them is one way to diminish a sense of false shame, which may account for the failure to obtain timely help.

At risk: LGBT individuals

Family and societal stigma and harassment may contribute to suicide risk factors among LGBT patients. For instance, a recent CDC study found that the prevalence of seriously considering suicide was substantially higher among LGBT high school students (42.8%) and those unsure of their sexual orientation (31.9%) than among heterosexual students (14.8%). In fact, 38.2% of LGBT students and 27.9% of unsure students went so far as to make a plan to attempt suicide as compared with 11.9% of heterosexual students. Further, 29.4% of LGBT and 13.7% of unsure students attempted suicide at least once as compared with 6.4% of heterosexual students who participated in this study. 1 Moreover, a recent survey demonstrated that transgender and gender nonconforming adults across all demographic categories exhibited a high prevalence of lifetime suicide attempts (41%). This far exceeds the 4.6% rate for the overall US population. 2

Although it would be a mistake to merely assume that LGBT patients and coworkers are at an elevated risk for suicide, these studies show that gender identity and sexual orientation are important factors to keep in mind when assessing for experiences, such as bullying, harassment, violence, and discrimination, that may lead to suicidal ideation. 3

At risk: Veterans

Studies of suicide rates among veterans demonstrate how this is a complex phenomenon that transcends racial, ethnic, and gender categories. A study of active duty veterans who served during the Iraq and Afghanistan wars indicated these findings:

• Both deployed and nondeployed veterans had a higher risk of suicide for 3 years after leaving the service.
• Deployed veterans had a lower risk of suicide compared with nondeployed veterans (41% versus 61%); 21.3% of deployed veteran deaths (1,650) were caused by suicide as of 2009, whereas 19.7% of nondeployed veteran deaths (7,703) were a result of suicide.
• Suicide rates for female veterans were about a third of that for male veterans. 1

In recognition of the difficulties that VA clinical staff members encounter in identifying patients at risk for suicide, a suicide risk algorithm was developed by studying veterans' clinical records. Researchers found that this model more accurately identified those at risk than clinical evaluation. The traditional methodology identified less than one third of high-risk patients. 2 These data drive home the need for us to increase our awareness of this growing problem and respond to it by improving our risk assessment skills.

INSTRUCTIONS Suicide risk assessment and prevention

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• Read the article. The test for this CE activity is to be taken online at http://nursing.ceconnection.com .
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• There's only one correct answer for each question. A passing score for this test is 13 correct answers. If you pass, you can print your certificate of earned contact hours and access the answer key. If you fail, you have the option of taking the test again at no additional cost.
• For questions, contact Lippincott Professional Development: 1-800-787-8985 .
• Registration deadline is September 4, 2020 .

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Lippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.0 contact hour, and the District of Columbia, Georgia, and Florida CE Broker #50-1223.

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Patient Safety and Managing Risk in Nursing

• Melanie Fisher - Northumbria University, UK
• Margaret Scott - Northumbria University, UK
• Description

Patient safety is a predominant feature of quality healthcare and something that every patient has the right to expect.  As a nurse, you must consider the safety of the patient as paramount in every aspect of your role; and it is now an increasingly important topic in pre-registration nursing programmes. This book aims to provide you with a greater understanding of how to manage patient safety and risk in your practice. The book focuses on the essentials that you need to know, and therefore provides a clear pathway through what can sometimes seem an overwhelmingly complex mass of rules, procedures and possible options.

Key features:

·         A practical introduction to patient safety and risk management written specifically for nurses and nursing students

·         Case studies and scenarios help you to apply patient safety and risk management principles to actual practice

·         Each chapter is mapped to the relevant NMC standards and Essential Skills Clusters so that you can see how you are meeting the professional requirements

·         Activities throughout help you to think critically and reflect on practice.

this book is essential for novice nurses and provides a good understanding of how to manage patient safety and risk in clinical practice, easy to read and relates extensively to the governing bodies.

Another excellent book from the Transforming Nursing Practice series. Well laid out, easy to read and full of helpful activities that are relevant to practice and assist in helping students to understand and apply the risk management principles to their own practice

A helpful, informative text . The text will help students to explore the role of the professional nurse in terms of managing risk in clinical practice. Issues of communication, assessment, Human factors and quality of care have been covered. The information is presented in a clear , logical and visually appealing way. I would recommend this book to all my students.

An useful review of several topics relevant to patient safety with application to nursing. I thought the interactive activities were very helpful.

useful for all types of health care professions

This book is succinct and full of key information. I deem it vital for our Quality and Safety Module.

Recommended this textfor students inthe thrid year working on preesebtaion based on this risk managing...

Easy to read and the content is very relevant for health and social care students

This book is very useful and I found it helpful for my students, accordingly, I put it in the course syllabus as a supplementary material to be used by the students because it covers some of the items in the course contents. the students were advised to buy the book as supplemental to the required textbook. thank you

A good introduction to patient safety.

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Risk Management: Understanding the Basics and Importance

In a business environment filled with uncertainties, how can business leaders steer their organizations toward sustainable success while navigating through the maze of potential risks?

One example of effective risk management in action is the case of Johnson & Johnson during the Tylenol crisis in 1982 . Faced with the crisis where cyanide-laced Tylenol capsules resulted in several deaths, Johnson & Johnson swiftly and decisively recalled all Tylenol products from the market, despite the financial implications. 

This move, driven by a commitment to consumer safety and ethical responsibility, not only managed the immediate risk but also rebuilt public trust in the brand. This incident is a classic example of how risk management extends beyond financial and operational risks to encompass ethical considerations and consumer trust.

The answer often lies at the executive level, where understanding and implementing effective risk management becomes a pivotal aspect of strategic decision-making. This process is crucial for day-to-day operations and shaping long-term business strategies and policies at the C-suite and board levels.

Risk management is the systematic process of identifying, assessing, and prioritizing potential risks and implementing strategies to minimize or mitigate their impact. 

It involves analyzing uncertainties and making informed decisions to protect organizations from potential harm or loss. Risk management is a critical component of effective decision-making and essential for the long-term success and sustainability of businesses and industries.

In today’s era, risk management strategies are increasingly influenced by the dig ital transformation of businesses. The rise of cyber risks, data privacy concerns, and the need for digital resilience are reshaping the risk landscape. Organizations are adopting digital tools and analytics, not only to comply with technological advancements but also to predict and mitigate risks more effectively.

We’ll explore the importance of risk management and how to implement an effective plan in the contemporary business landscape, especially from a strategic executive perspective.

• What types of risks are there?

Importance of risk management

Risk management process.

• Enterprise risk management (ERM)

How to create an effective risk management plan

Embrace a culture of continuous learning and adaptation in risk management, types of risks.

In the business realm, myriad risks are categorized based on their nature and source. Here’s an insight into some types of risks:

• Operational risk . Arises from internal processes, people, and systems.
• Financial risk . Related to financial operations and transactions.
• Strategic risk. Stems from business strategies and industry changes.
• Compliance risk. Due to legal and regulatory requirements.
• Reputational risk. Impacts public perception and brand reputation.
• Market risk. From market dynamics like price and demand fluctuations.
• Credit risk. Due to potential default on financial obligations.
• Technology risk. Such as cybersecurity threats and system failures.

Understanding these risks is the steppingstone to developing a robust risk management framework, ensuring business longevity amidst a landscape of uncertainties.

Risk management plays a vital role in various industries, as it helps organizations anticipate and address potential threats and uncertainties. By proactively managing risks, businesses can minimize financial losses, protect their reputation, and ensure the safety and well-being of their employees and stakeholders. 

Moreover, risk management enables organizations to seize opportunities and make informed decisions, leading to improved performance and competitive advantage. 

IMD’s Boards and Risks program provides board members with the opportunity to hone their risk oversight capabilities and ensure they’re well-equipped to guide their organizations through the complex landscape of contemporary business risks.

• Finance. In the financial sector, risk management is crucial for banks, insurance companies, and investment firms. These institutions face a wide range of risks, including credit risk, market risk, operational risk, and liquidity risk. Effective risk management practices in the financial industry help ensure stability and prevent financial crises, as demonstrated by the global financial crisis of 2008 .
• Health care. The health care industry relies heavily on risk management to ensure patient safety and quality of care. Health care organizations face risks related to medical errors, patient privacy breaches, and regulatory compliance. By implementing robust risk management strategies, providers can identify and mitigate potential risks, leading to improved patient outcomes and reduced legal liabilities.
• Project management. Risk management is equally important in project management, where uncertainties and potential risks can significantly impact project success. By incorporating risk management into project planning and execution, project managers can identify potential obstacles, allocate resources effectively, and implement contingency plans to minimize project delays and cost overruns.
• Information technology. Information technology (IT) is another sector where risk management is of utmost importance. With the increasing reliance on digital systems and the rise of cyberthreats , organizations must implement robust risk management practices to protect sensitive data, maintain system integrity, and ensure business continuity. Cybersecurity risks, such as data breaches and malware attacks, can have severe consequences, including financial losses and reputational damage.
• Supply chain management. Supply chain management is yet another area where effective risk management is critical. Supply chains are vulnerable to various risks, such as disruptions in logistics, supplier failures, and natural disasters. By implementing risk management strategies, organizations can identify potential vulnerabilities, establish alternative supply sources, and develop contingency plans to minimize the impact of supply chain disruptions.

The risk management process is a structured approach that enables organizations to identify, assess, mitigate, and monitor risks. Implementing a thorough risk management process is crucial for understanding and preparing for the potential risks that come with operating in any industry. 

Adopting standard risk management practices, like those outlined by the International Organization for Standardization (ISO), can benefit businesses by providing a framework to manage risks effectively. 

Risk identification

Risk identification is the initial step in the risk management process. It involves recognizing and listing all possible risks that might affect the organization, whether they’re operational, financial, technological, reputational, or otherwise. For example, a retail company might identify the risk of data breaches that could potentially expose sensitive customer information.

Various tools and techniques can be used for risk identification including SWOT analysis, historical data analysis, stakeholder interviews, and expert consultations.

Risk assessment

Once risks have been identified, the next step is to assess them based on their likelihood of occurrence and the potential impact they could have on the organization. 

As an example, a financial institution might assess the potential financial and reputational impact of fraud risks and determine the likelihood of occurrence is high due to inadequate fraud detection systems.

Risk assessment allows for a better understanding of the risks and aids in prioritizing them. This stage often involves the creation of a risk matrix and a risk register to visualize the severity and priority of each risk.

Alongside traditional methods, a data-driven approach is revolutionizing risk assessment. Advanced data analytics, AI, and machine learning are now pivotal tools in identifying and evaluating risks. 

These technologies enable organizations to process vast amounts of data, recognize patterns, and predict potential risks with unprecedented accuracy. By leveraging these tools, businesses can gain deeper insights into potential threats, leading to more informed decision-making.

Risk mitigation

Risk mitigation involves developing and implementing strategies to address the identified risks. The aim is to reduce the likelihood of the risks or lessen their impact should they occur. 

For example, a health care organization might implement stricter data security measures and train staff on cybersecurity best practices to mitigate the risk of cyberattacks .

Common risk mitigation strategies include risk avoidance, risk reduction, risk transfer, risk treatment, and implementing risk controls to ensure a balanced approach. It’s crucial to align mitigation strategies with organizational objectives to ensure a balanced approach.

Risk monitoring

Risk monitoring is the ongoing process of tracking and reviewing the identified risks and the effectiveness of the mitigation strategies put in place. Continuous monitoring ensures the organization is well-prepared to respond to changes in the risk profile over time. 

Effective risk monitoring includes regular reporting, reviewing, and updating the risk management plan to ensure it remains relevant and effective in the current business environment.

Enterprise risk management ( ERM )

Enterprise risk management (ERM) embodies a comprehensive approach to risk management that extends beyond traditional methods to encompass a broader range of business risks. 

Unlike conventional risk management, which may focus on isolated domains such as operational, financial, or technological risks, ERM integrates risks from various facets of a business and offers a unified view. This consolidated perspective is particularly beneficial for C-suite leaders and board members, as it facilitates strategic decision-making. 

By understanding the interdependencies and cumulative impact of different risks on overall business objectives, executives can align risk management with their strategic planning, enhancing their organization’s resilience and adaptability.

For example, consider how Apple has implemented ERM to manage its complex global operations. Apple’s ERM framework encompasses various risks, including supply chain disruptions, intellectual property issues, and market volatility. 

By integrating this broad range of risks, Apple can make strategic decisions that balance innovation with risk, such as diversifying its supplier base and investing in robust cybersecurity measures. This approach has helped Apple not only to mitigate risks but also to seize growth opportunities in the fast-evolving tech industry.

This comprehensive analysis and assessment of potential risks aid in devising robust business continuity plans, ensuring the organization remains operational and continues to meet its objectives even in the face of adversities.

For example, a hospital system implementing ERM could identify potential risks related to natural disasters and infectious disease outbreaks. By aligning its ERM findings with its business continuity plans, the hospital is better prepared to maintain operations during a pandemic and provide continuous care for patients.

Furthermore, ERM contributes to achieving business benchmarks by fostering a culture of informed decision-making. Identifying and analyzing risk events in a structured manner provides valuable insights that aid in setting realistic and attainable benchmarks. 

It also offers a clear pathway for monitoring progress toward achieving these benchmarks and makes sure the risk management initiatives are aligned with overall business success.  An illustration of these benefits can be seen in a financial services firm employing ERM to align its risk management strategies with its business benchmarks in customer satisfaction, regulatory compliance, and financial performance. Through continuous monitoring and adjustment of its risk management practices, the firm can achieve and exceed its set benchmarks, showcasing the value of a holistic risk management approach.

Creating an effective risk management plan is pivotal for business leaders who want to safeguard the organization against unforeseen adversities. Here’s a step-by-step guide to aid leaders in developing a robust plan.

1. Identify risks

Begin with a thorough identification process to list down all possible risks that could affect your organization. Use tools like SWOT analysis, brainstorming sessions, and historical data analysis to uncover potential risks. Engage different departments to ensure a comprehensive identification process.

2. Assess risks

Assess the identified risks based on their likelihood and potential impact on the organization. Utilize risk assessment matrices to prioritize risks and understand their implications better. This step should provide a clear insight into which risks need immediate attention.

3. Develop mitigation strategies

Formulate strategies aimed at mitigating risks and the impact of identified risks. Each strategy should correspond to a specific risk and might range from risk avoidance to risk acceptance. Additionally, consider investing in insurance policies to transfer certain risks.

4. Allocate resources

Allocate necessary resources like finances, personnel, and technology to support the implementation of your risk mitigation strategies. Ensure there are clear budgets and responsible persons assigned to each strategy.

5. Communicate and train

Communicate the risk management plan to all stakeholders and train relevant personnel on their roles within the plan. Effective communication and training ensure everyone is aligned and equipped to manage risks effectively.

6. Implement the plan

Put the plan into action by implementing the formulated risk mitigation strategies. Monitor the implementation process to confirm it aligns with the plan, and make adjustments as necessary to address any challenges that arise.

7. Monitor and review

Continuously monitor the effectiveness of the risk management plan and the evolving risk landscape. Regular reviews help identify any gaps in the plan, so leaders can make necessary updates..

8. Establish a feedback loop

Create a feedback mechanism to gather insights from the implementation process. Encourage stakeholders to report on the effectiveness of risk mitigation strategies, and use this feedback to improve the response plan.

9. Consult experts

Engage risk management experts or enroll in specialized programs like IMD’s Boards and Risks program , which can help board members upgrade their risk oversight capabilities by offering a structured approach toward understanding and managing various business risks

10. Foster continuous improvement

Promote a culture of continuous improvement by learning from the successes and failures of the risk management process. Analyze performance data, stay updated on evolving best practices, and strive for continuous enhancement of your risk management plan to ensure it remains robust and relevant.

Throughout this exploration, we’ve underscored the pivotal role of risk management in steering organizations through the myriad of uncertainties inherent in today’s business landscape. 

From understanding the risk management process to the broader perspective offered by enterprise risk management (ERM), the journey toward effective risk governance is both a necessity and an opportunity for organizational resilience and sustainable success.

As the business ecosystem evolves, embracing a culture of continuous learning and adaptation in risk management is imperative. Engage with IMD’s Board at Risk learning journey to further enhance your risk management acumen and prepare your organization to not only withstand adversities but to thrive amidst them.

To quote O. Sarl Simonton, “In the face of uncertainty, there is nothing wrong with hope.” Coupling hope with a robust risk management strategy is the blueprint for enduring success in an unpredictable world.

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A risk assessment and management strategy for community nursing

• PMID: 12271212
• DOI: 10.12968/bjcn.2000.5.6.7397

Many nursing interventions carry risks of harm to the patient, the nurse or the general public, and the potential for subsequent litigation or censure. This article proposes a six-point risk management strategy, which, if implemented, could reduce the chance of potential harm and litigation within a community nursing service. The strategy encompasses organizational, cultural, clinical, employee, environmental, and incident-reporting issues. A policy statement is proposed from which a risk management strategy could be developed. This is underpinned by the acceptance and ownership of risk management by all managers and clinicians, which is best achieved through a culture of honesty and openness, and where the management of risk is considered one of the fundamental duties of every member of staff. The strategy aims to enable the creation of a more coordinated, systematic and focused approach to the management of risks.

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• Introduction
• Conclusions
• Article Information

Geocoded locations of US Centers for Medicare & Medicaid Services–certified nursing homes are displayed as of December 1, 2017. Nursing home locations are superimposed on a visual adaptation of the US Wildfire Hazard Potential Index that summarizes the nationalized wildfire potential with 270-m resolution. Two thresholds of nationalized risk are displayed for areas at or exceeding the 85th and 95th percentiles.

eTable 1. Frequency of Deficiency Codes for Western US Nursing Homes

eTable 2. Prevalence of Exposed Facilities Under Different Exposure Thresholds

eTable 3. Summary of Emergency Preparedness Deficiencies by US Centers for Medicare and Medicaid (CMS) Regional Office and Potential Wildfire Exposure

eTable 4. Associations Between Wildfire Exposure and Emergency Preparedness Deficiencies for 2 Alternative Exposure Definitions

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Festa N , Throgmorton KF , Davis-Plourde K, et al. Assessment of Regional Nursing Home Preparedness for and Regulatory Responsiveness to Wildfire Risk in the Western US. JAMA Netw Open. 2023;6(6):e2320207. doi:10.1001/jamanetworkopen.2023.20207

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Assessment of Regional Nursing Home Preparedness for and Regulatory Responsiveness to Wildfire Risk in the Western US

• 1 Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
• 2 National Clinician Scholars Program at Yale University, New Haven, Connecticut
• 3 Harvey Cushing/John Hay Whitney Medical Library, School of Medicine, Yale University, New Haven, Connecticut
• 4 Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
• 5 School of Public Health, Brown University, Providence, Rhode Island
• 6 Warren Alpert Medical School, Brown University, Providence, Rhode Island
• 7 Center of Innovation for Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island
• 8 Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
• 9 Department of Sociology, Yale University, New Haven, Connecticut

Question   Are nursing homes at elevated risk of wildfire exposure likelier to meet federal emergency preparedness standards or subject to greater regulatory oversight?

Findings   In this cross-sectional study of 2218 nursing homes in the western US, regional heterogeneity in nursing home emergency preparedness for wildfire episodes was observed, and facilities at elevated exposure risk in the Mountain West and Pacific Northwest had poorer compliance with emergency preparedness criteria than unexposed facilities. Of the noncompliant facilities, exposed nursing homes in the Mountain West incurred longer times to reinspection than their unexposed counterparts.

Meaning   These findings suggest that there are opportunities to improve the regional responsiveness of nursing homes and regulatory oversight to surrounding environmental hazards.

Importance   It is uncertain whether emergency preparedness and regulatory oversight for US nursing homes are aligned with local wildfire risk.

Objective   To evaluate the likelihood that nursing homes at elevated risk of wildfire exposure meet US Centers for Medicare & Medicaid Services (CMS) emergency preparedness standards and to compare the time to reinspection by exposure status.

Design, Setting, and Participants   This cross-sectional study of nursing homes in the continental western US from January 1, 2017, through December 31, 2019, was conducted using cross-sectional and survival analyses. The prevalence of high-risk facilities within 5 km of areas at or exceeding the 85th percentile of nationalized wildfire risk across areas overseen by 4 CMS regional offices (New Mexico, Mountain West, Pacific/Southwest, and Pacific Northwest) was determined. Critical emergency preparedness deficiencies cited during CMS Life Safety Code Inspections were identified. Data analysis was performed from October 10 to December 12, 2022.

Main Outcomes and Measures   The primary outcome classified whether facilities were cited for at least 1 critical emergency preparedness deficiency during the observation window. Regionally stratified generalized estimating equations were used to evaluate associations between risk status and the presence and number of deficiencies, adjusted for nursing home characteristics. For the subset of facilities with deficiencies, differences in restricted mean survival time to reinspection were evaluated.

Results   Of the 2218 nursing homes in this study, 1219 (55.0%) were exposed to elevated wildfire risk. The Pacific/Southwest had the highest percentage of both exposed (680 of 870 [78.2%]) and unexposed (359 of 486 [73.9%]) facilities with 1 or more deficiencies. The Mountain West had the largest difference in the percentage of exposed (87 of 215 [40.5%]) vs unexposed (47 of 193 [24.4%]) facilities with 1 or more deficiencies. Exposed facilities in the Pacific Northwest had the greatest mean (SD) number of deficiencies (4.3 [5.4]). Exposure was associated with the presence of deficiencies in the Mountain West (odds ratio [OR], 2.12 [95% CI, 1.50-3.01]) and the presence (OR, 1.84 [95% CI, 1.55-2.18]) and number (rate ratio, 1.39 [95% CI, 1.06-1.83]) of deficiencies in the Pacific Northwest. Exposed Mountain West facilities with deficiencies were reinspected later, on average, than unexposed facilities (adjusted restricted mean survival time difference, 91.2 days [95% CI, 30.6-151.8 days]).

Conclusions and Relevance   In this cross-sectional study, regional heterogeneity in nursing home emergency preparedness for and regulatory responsiveness to local wildfire risk was observed. These findings suggest that there may be opportunities to improve the responsiveness of nursing homes to and regulatory oversight of surrounding wildfire risk.

Because nursing homes are affected by a confluence of factors that increase resident vulnerability, their adaptation to environmental hazards, such as wildfires, is a federal priority. 1 The US Centers for Medicare & Medicaid Services (CMS) published its Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers in 2016, setting the standards to which nursing homes, among other providers, are subject during emergency preparedness inspections. 2 This rule encourages nursing homes to adopt an all-hazards approach to emergency preparedness, under which facilities are responsible for appraising and preparing for potential risks, including environmental hazards. While the intentional flexibility of the all-hazards framework promotes context-responsive emergency planning without imposing an undue regulatory burden, 3 , 4 recent federal audits have demonstrated patterns of emergency preparedness deficiencies that are misaligned with prominent environmental risks. 5 , 6 Because the probability of weather conditions that are conducive to wildfire episodes has been increasing in the US, 7 , 8 nursing home preparedness for wildfires is of particular importance in regions where such episodes are common.

While federal audits offer vital details regarding nursing home emergency preparedness, these reports are often constrained to a small subset of facilities within individual states. 5 For this reason, relatively little is known about the regional alignment between specific environmental hazards and nursing home emergency preparedness or patterns of regulatory oversight. 9 Improved understanding of such regional relationships is important because CMS regional offices (ROs) oversee state enforcement actions and standardized compliance with federal emergency preparedness criteria. 4 Ensuring that nursing homes are prepared to respond to surrounding environmental hazards will become increasingly important if the frequency of community exposure to wildfires continues to increase, as has been projected. 10 Direct exposure to heat and particulate matter from wildfire episodes places residents at heightened risk of morbidity and mortality. 11 , 12 Moreover, inadequate nursing home preparedness for wildfires may contribute to resident abandonment and evacuation to non–health care settings. 13 - 15

In this study, we assessed whether emergency preparedness by US nursing homes, as measured by adherence to CMS standards, is commensurate with facilities’ risk of wildfire exposure. Further, we evaluated whether patterns of regulatory oversight differ according to facilities’ wildfire exposure risk across CMS regulatory regions. We hypothesized that nursing homes with the highest exposure risk would exhibit greater compliance with CMS emergency preparedness standards compared with lower-risk facilities. We also hypothesized that high-risk nursing homes with documented emergency preparedness deficiencies would undergo CMS Life Safety Code (LSC) reinspection sooner than lower-risk facilities. To accomplish our objectives, we estimated regionally stratified associations between location in an area of heightened wildfire risk and compliance with CMS emergency preparedness standards. We also evaluated regionally stratified associations between wildfire exposure and time to LSC reinspection for facilities with critical emergency preparedness deficiencies. The results of this study should inform policies to better align nursing home emergency preparedness and regulatory oversight with local wildfire risk within and across regulatory regions.

This cross-sectional study did not involve human participants and was deemed exempt from review and informed consent by the Yale University Institutional Review Board under 45 CFR §46.104. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We used the CMS Provider Information catalog to identify certified nursing homes within the continental western US, where wildfires are most common; 2357 such nursing homes were found. 16 These homes included facilities in Arizona, California, Colorado, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. We evaluated facilities’ emergency preparedness deficiencies based on inspections from January 1, 2017, to December 31, 2019. We omitted 139 nursing homes because they had missing facility characteristics or location data during the observation window, leading to a final analytic sample of 2218 facilities.

We used the third edition of the US Wildfire Hazard Potential Index (WHPI) to evaluate wildfire potential using local landscape conditions. 17 The WHPI contains information regarding local wildfire hazard potential at a spatial resolution of 270 m 2 , based on simulations under tens of thousands of hypothetical landscape and meteorological conditions to estimate burn probability within each 270-m 2 pixel. 17 - 19 The models consider landscape conditions circa 2014 and were updated in 2020. 18 , 19

We defined high-risk (exposed) nursing homes as those located within 5 km of areas at or exceeding the 85th percentile of nationalized wildfire hazard potential for the US. This working definition of exposure status reflects risk thresholds and does not necessarily indicate direct exposure to a wildfire episode during the observation period. The primary risk threshold corresponds to cut points for high (85th to 95th percentiles) and very high (96th to 99th percentiles) nationalized wildfire hazard potential within the WHPI. 18 We refrained from defining separate percentile thresholds for each state because such an approach would understate wildfire risk to facilities in states with higher average risk, which are concentrated in the western US.

We compiled emergency preparedness deficiencies using CMS LSC inspections over 3 years from January 2017 to December 2019. 20 We used emergency preparedness deficiencies as a proxy for nursing home emergency preparedness. From the 252 potential emergency preparedness deficiencies, we selected a subset deemed to be most critical in accordance with prior literature and emergency preparedness guidance (eTable 1 in Supplement 1 ). 9 , 21 - 23 We also compiled information regarding the scope and severity of each deficiency, using the following categories defined by CMS (from least to most severe): (1) no actual harm with potential for minimal harm, (2) no actual harm with potential for more than minimal harm, (3) actual harm that is not immediate jeopardy, and (4) immediate jeopardy to resident health or safety. 24

We defined 3 outcome measures. Our primary outcome classified whether facilities were cited for at least 1 critical emergency preparedness deficiency during the observation window. Our second outcome summed the total number of critical emergency preparedness deficiencies per inspection. Our third outcome quantified the mean time to reinspection for nursing homes with documented critical emergency preparedness deficiencies cited during their first inspection within the observation window.

We used the CMS Provider Information files to evaluate the size (number of beds), ownership status (proprietary vs nonprofit or government ownership), and CMS 5-star ratings for the Staffing, Health Inspection, and Quality domains. The CMS ratings range from 1 to 5, with higher scores indicating better performance. We used LTCFocus (Long-term Care Focus) data to link lagged (2018) indicators of nursing home payer mix, as indicated by the percentage of residents within each facility primarily insured by Medicaid. 25 LTCFocus is sponsored by the National Institute on Aging through a cooperative agreement with the Brown University School of Public Health. We used the National Center for Health Statistics designations to classify whether facilities were located within a rural county. 26

We first estimated the percentage of high-risk nursing homes (facilities ≤5 km from areas at or exceeding the 85th percentile of nationalized wildfire risk) using their geocoded addresses. We compared facility characteristics between nursing homes according to their wildfire exposure status. We also quantified the prevalence of critical emergency preparedness deficiencies for nursing homes, grouping states according to the CMS RO that they belong to: RO 6 (New Mexico), RO 8 (Mountain West), RO 9 (Pacific/Southwest), and RO 10 (Pacific Northwest). Because they supervise enforcement actions and compliance with federal emergency preparedness standards, we evaluated regional patterns of emergency preparedness and oversight corresponding to CMS RO designations. 4

We evaluated cross-sectional associations between location within a wildfire-exposed area and the presence and count of emergency preparedness deficiencies using regionally stratified generalized estimating equations with binomial and negative binomial distributions, clustered by facility identification numbers, with robust SEs. To address potential confounding by facility or area characteristics, we adjusted for rurality, ownership, size, payer mix, and CMS ratings in the Health Inspection, Staffing, and Quality domains. Because of sparseness of the lowest scores in some subgroups, the CMS rating was dichotomized in adjusted analyses to indicate whether facilities received a high score (4-5 stars) in each domain. In sensitivity analyses, we reran the models for the 4 regional strata after increasing the severity of the wildfire exposure threshold to within 2.5 km from areas at or exceeding the 85th percentile of nationalized wildfire risk and within 2.5 km from areas at or exceeding the 95th percentile of nationalized wildfire risk.

Last, we conducted a survival analysis to estimate associations between wildfire exposure and the mean time to reinspection for the subset of facilities with a critical emergency preparedness deficiency. Because covariates in our adjusted model violated the proportional hazards assumption, we estimated the difference in time to first reinspection (in days) between exposed and unexposed facilities over a follow-up period of 15 months using restricted mean survival time analysis for each regional stratum. We calculated adjusted restricted mean survival time differences between exposed and unexposed nursing homes, adjusting for the number and average scope and severity of emergency preparedness deficiencies assigned during the first inspection within the observation period as well as the previously described area and facility characteristics.

We used a 2-tailed P value threshold of .05 to determine statistical significance. We conducted analyses using ArcGIS Pro, version 3.0 (Esri); Python, version 3 (Python Software Foundation); and Stata, version 17 (StataCorp). Data analysis was performed from October 10 to December 12, 2022.

The Figure displays the geocoded locations of the 2218 nursing homes in this study relative to areas with elevated risk of wildfire exposure. Of these nursing homes, 1219 (55.0%) were located within 5 km of areas at or exceeding the 85th percentile of nationalized wildfire risk. The Pacific/Southwest had the highest percentage of exposed nursing homes (870 of 1356 [64.2%]), followed by the Mountain West (215 of 408 [52.7%]) (eTable 2 in Supplement 1 ). As shown in Table 1 , exposed facilities were smaller, with lower Medicaid share and proprietary ownership. The CMS ratings in the Health Inspection, Quality, and Staffing domains were comparable across the 2 groups. Similar proportions of exposed and unexposed facilities were located in rural counties across the overall sample. The Mountain West had the greatest percentage of rural facilities (97 of 408 [23.8%]), while the Pacific/Southwest had the lowest percentage of rural nursing homes (18 of 1356 [1.3%]). Less than 10% of nursing homes in New Mexico (5 of 64 [7.8%]) and the Pacific Northwest (23 of 390 [5.9%]) were located within rural areas. Exposed and unexposed facilities also underwent a similar number of LSC inspections during the observation period (mean [SD], 2.5 [0.6] vs 2.6 [0.6]).

eTable 3 in Supplement 1 provides the prevalence and number of critical emergency preparedness deficiencies by region and exposure status. The Pacific/Southwest had the highest percentage of both exposed (680 of 870 [78.2%]) and unexposed (359 of 486 [73.9%]) facilities with at least 1 critical emergency preparedness deficiency. The Mountain West had the largest difference in the percentage of exposed (87 of 215 [40.5%]) vs unexposed (47 of 193 [24.4%]) facilities with at least 1 critical emergency preparedness deficiency and the lowest prevalence of facilities with at least 1 deficiency across all regions. Facilities in the Pacific Northwest had the greatest mean (SD) number of deficiencies per nursing home (4.3 [5.4]).

Overall, the most common emergency preparedness deficiencies included failure to conduct emergency-related testing and exercise requirements, implement emergency and standby power systems, and address subsistence needs for staff and patients (eTable 1 in Supplement 1 ). As given in Table 2 , the Pacific/Southwest had the highest percentage of facilities with failure to implement emergency and standby power systems (374 of 1356 [27.6%]), while the Pacific/Southwest and Pacific Northwest had the highest percentages of facilities that failed to address subsistence needs for staff and patients (230 of 1356 [17.0%] and 115 of 390 [29.5%]).

Table 3 provides the adjusted regional associations between wildfire exposure risk and the likelihood and number of critical emergency preparedness deficiencies. Exposed nursing homes had a greater likelihood of a critical emergency preparedness deficiency than unexposed facilities within the Mountain West (odds ratio, 2.12 [95% CI, 1.50-3.01]) and Pacific Northwest (odds ratio, 1.84 [95% CI, 1.55-2.18]). We observed a similar pattern with respect to the number of critical emergency preparedness deficiencies in the Pacific Northwest (rate ratio, 1.39 [95% CI, 1.06-1.83]). In contrast, associations were not observed for New Mexico or the Pacific/Southwest.

Table 4 summarizes the regional mean differences in time between the first inspection and the subsequent LSC inspection for nursing homes with a critical emergency preparedness deficiency by exposure status. In the unadjusted analysis, exposed nursing homes had longer mean durations to reinspection than their unexposed counterparts. Exposed nursing homes in New Mexico experienced the longest absolute duration to reinspection (mean [SE], 406.1 [23.1] days) compared with other regions. Unexposed nursing homes in the Mountain West had the shortest absolute duration to reinspection (mean [SE], 275.9 [28.1] days) compared with other regions. The adjusted difference for the Mountain West was statistically significant, with exposed nursing homes reinspected a mean of 91.2 days (95% CI, 30.6-151.8 days) later than unexposed facilities.

The magnitude and significance of associations were similar for the 2 alternative exposure definitions (eTable 4 in Supplement 1 ). Overlap between the point estimates for the first alternative definition and 95% CIs for the second did not support a dose-response association between greater exposure risk and emergency preparedness.

More than half of nursing homes in the continental western US are within 5 km of areas with elevated wildfire risk, heightening the importance of their emergency preparedness. Critical emergency preparedness deficiencies, including those focusing on competencies that are necessary to safely shelter residents in place or evacuate them when appropriate, were prevalent within each regulatory region. 27 We observed geographic variation in the association between nursing home exposure and emergency preparedness. Contrary to expectations, we observed either no association or an increased likelihood and number of deficiencies for exposed facilities. Our findings suggest that high-risk facilities in the Mountain West and Pacific Northwest were more likely to have emergency preparedness deficiencies than their unexposed counterparts. Also contrary to our hypotheses, we observed either no association between exposure and the mean time to reinspection or paradoxically longer durations for exposed facilities. High-risk facilities in the Mountain West were reinspected, on average, 91.2 days later than lower-risk facilities.

The poorer emergency preparedness of high-risk nursing homes suggests that management and staff may be unaware of surrounding wildfire risk. The comparable, if not longer, time to reinspection for high-risk facilities with documented emergency preparedness deficiencies suggests that regulators may also be unfamiliar with local wildfire risk. The longer duration to reinspection for high-risk facilities in the Mountain West may be due, at least in part, to challenges in maintaining regulatory oversight in regions with a high concentration of rural areas. Although our models adjusted for rurality, data were not available on more specific factors that may correlate with rurality or the concentration of rural counties within a region, such as driving time between facilities and the prevalence of regulators. Greater than 20% of nursing homes in the Mountain West were located within rural areas, compared with less than 10% in other regions. In regions where nursing homes may be less accessible or regulatory staff may be less available, it would be prudent to prioritize high-risk nursing homes with outstanding deficiencies for reinspection.

Projected increases in community wildfire exposure 10 heighten the importance of adequate emergency preparedness and increased inspection frequency for nursing homes with greater exposure risk. Considering the unique vulnerability of nursing home residents to external stressors, including environmental hazards, emergency preparedness should be better aligned with the likelihood of exposure to wildfire episodes. Prior research has shown significant increases in morbidity and mortality among residents of congregate care settings exposed to disasters. 28 , 29 The CMS all-hazards approach to emergency preparedness guidance promotes comprehensive nursing home preparation for salient risks—ranging from infectious diseases to local environmental hazards. 30 While this framework encourages nursing homes to engage with municipal disaster planning agencies, clear standards to enforce the strength or adequacy of these partnerships have not been developed. 3 , 30 , 31 Understanding how partnerships with municipal disaster planning agencies could improve the sensitivity of both nursing home staff and regulators to pertinent hazards may better align emergency preparedness with local environmental risks. These partnerships may also aid in identifying prevalent regional exposures that could warrant tailored emergency preparedness standards. For example, updating building code guidance on acceptable ventilation standards could reduce residents’ exposure to particulate matter in wildfire-prone areas. Improved oversight of these partnerships by CMS ROs could expedite progress toward these ends.

This study has limitations. A standard distance-based evacuation threshold does not exist due to inherent challenges in predicting wildfire behavior and appropriate evacuation radii. 32 , 33 Because municipal wildfire guidelines cite potential ember-induced secondary fires up to 16 km from the main fire front, 34 our chosen distance thresholds (5 and 2.5 km) are conservative. In addition, our analysis focused on a single environmental exposure that is concentrated within the western US. As additional geospatial information becomes available, future research should incorporate multiple categories of environmental risk, such as flooding and earthquakes.

We cannot exclude the possibility that state surveyors were more vigilant in issuing emergency preparedness deficiencies based on perceived wildfire exposure risk. To address this limitation, we conducted sensitivity analyses that evaluated associations between emergency preparedness and increasingly severe exposure thresholds. We also evaluated the mean time to reinspection based on deficiency and exposure status for each nursing home. The results of our cross-sectional sensitivity analyses did not suggest a dose-response association between the severity of exposure risk and the likelihood of critical emergency preparedness deficiencies. Nor did the results of the survival analysis suggest that exposure status expedited time to reinspection for noncompliant facilities. Nonetheless, we could not fully account for differences in surveyors’ sensitivity to local environmental risk in our analyses.

Our evaluation assumes that administrative deficiencies are acceptable indicators of nursing homes’ emergency preparedness, but administrative preparedness may not always translate to effective emergency planning or response. 35 We cannot exclude the possibility that some of the selected deficiencies are less germane to the execution of an effective emergency response plan. However, the select deficiencies included within the outcome definition are well aligned with national emergency preparedness guidance and prior literature linking preparedness to resident outcomes. 22 , 23 , 36

The observational nature of this study did not permit us to evaluate potential mechanisms that could explain regional differences in the emergency preparedness of nursing homes at increased risk of wildfire exposure. Qualitative studies that evaluate regional variation in organizational or regulatory emergency preparedness practices could provide complementary information.

Aligning nursing home emergency preparedness with local wildfire risk is important to resident safety. Regional variation in the emergency preparedness of nursing homes with an elevated risk of exposure to wildfire was observed in this study. Our findings suggest that nursing homes may benefit from enhanced enforcement of partnerships with local emergency planning agencies, which are better equipped to appraise environmental risks and call attention to nursing homes with disparate wildfire exposure risk. This would permit regulators to prioritize exposed nursing homes with outstanding, severe, or recurrent emergency preparedness deficiencies for reinspection and enhanced oversight. The CMS ROs are well positioned to accelerate progress toward nursing home emergency preparedness and regulatory oversight that are commensurate with surrounding environmental risks.

Accepted for Publication: May 10, 2023.

Published: June 26, 2023. doi:10.1001/jamanetworkopen.2023.20207

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Festa N et al. JAMA Network Open .

Corresponding Author: Natalia Festa, MD, MBA, National Clinician Scholars Program at Yale University, 333 Cedar St, PO Box 208088, New Haven, CT 06510 ( [email protected] ).

Author Contributions: Dr Festa and Ms Throgmorton had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Festa.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Festa, Throgmorton, Dosa.

Critical revision of the manuscript for important intellectual content: Festa, Davis-Plourde, Chen, Zang, Kelly, Gill.

Statistical analysis: Festa, Davis-Plourde, Zang.

Obtained funding: Festa.

Administrative, technical, or material support: Chen.

Supervision: Dosa, Zang, Gill.

Conflict of Interest Disclosures: Dr Gill reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

Funding/Support: Dr Festa was supported by training grant T32 AG019134 from the National Institute on Aging (NIA) and by Clinical and Translational Science Award TL1 TR001864 from the National Center for Advancing Translational Sciences (NCATS). Dr Davis-Plourde was partially funded by Yale Clinical and Translational Science Award UL1 TR001863 from NCATS. The study was conducted at the Yale Claude D. Pepper Older Americans Independence Center, which is supported by grant P30 AG021342 from the NIA.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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Risk management in the NHS: governance, finance and clinical risk

Waterford Institute of Technology, Ireland Nottingham University Business School

Introduction

Health services are inherently risky: their core activities involve a response to unpredictable events where the potential for loss (both financial and non-financial) is high. Moreover, the responses themselves have uncertain consequences when things go wrong, and healthcare providers need to be aware of the risks they face in order to manage them in the interests of both patients and staff. Risk management has been defined as the systematic identification, assessment and evaluation of risk. 1 Used properly in healthcare, it can not only be a process to report incidents, but also minimise the harm that clinical or resourcing errors can cause to patients and staff. From this perspective, the risk manager's remit in the NHS covers a wide range of activities–from the assessment and identification of risks through financial risk-transfer measures to investment in the quality of clinical care and beyond. The practice of risk management has developed and widened considerably in the NHS in the last decade in response to several key reports including An organisation with a memory , 2 which highlighted the need to learn from clinical error, and Standards for better health , which outlined potential improvements to the quality of care across several dimensions. 3

Moreover, risk management can be considered as part of the broader area of clinical governance which is defined by Chandraharan and Arulkumaran as a ‘framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’. 4 Risk management encompasses many aspects of clinical governance, from risk reporting (and response to complaints) to audit, guidelines, risk assessments (risk registers) and training. 1 In 2009, the Audit Commission recommended that trusts should ‘review their risk management arrangements–including the way in which risks are reported to the board’ and that the Department of Health as well as Monitor (the regulator of foundation trusts (FTs)) should ‘consider further incentives and sanctions to reward good governance through greater autonomy and take action to address shortfalls where they arise’. 5

This paper explores this theme–the inter-relationship between good governance, financial incentives and clinical risk management–and provides an overview of recent developments together with some evidence gleaned from views expressed by key decision takers within the NHS. Firstly, rating systems used within the NHS to classify hospitals according to the quality of their risk management activities are reviewed.

Risk ratings in the NHS

Nhsla risk management standards.

A risk management programme was introduced by the NHS Litigation Authority (NHSLA) in 1995, although it was 2000 before it was fully implemented. The core of this programme is provided by a range of NHSLA standards and assessments, and it is a requirement of continued membership of the Clinical Negligence Scheme for Trusts (CNST) that hospitals are subject to audit by the NHSLA. A set of risk management standards for each type of healthcare organisation was developed incorporating organisational, clinical, and health and safety risks ( www.nhsla.com ).

All the NHSLA standards are divided into three ‘levels’. NHS organisations which achieve success at level one in the relevant standards receive a 10% discount on their CNST contributions, with discounts of 20% and 30% available to those passing to levels two and three respectively. Members of the CNST scheme are required to achieve level one compliance and are assessed on an annual basis until this is achieved. Organisations at level one are assessed against the relevant standard(s) once every two years and those at levels two and three at least once in any three-year period, although organisations may request an earlier assessment if they wish to move up a level. The discount earned by members is applied to contributions in the financial year following a successful assessment and is valid for two years. Organisations which fail an assessment are required to be assessed at the level assigned in the following financial year.

Monitor's governance risk ratings

Monitor uses the term governance to describe the effectiveness of an NHS FT's leadership. It uses performance measures, such as whether FTs are meeting national targets and standards (eg a reduction in methicillin-resistant Staphylococcus aureus (MRSA) rates), together with a range of other governance measures such as community representation, appropriate board roles and structures, clinical quality and service performance. Specifically, it requires evidence that boards address and resolve any risks that have been identified. Trusts are rated red (significant breach of terms of authorisation), amber-red (material concerns), amber-green (limited concerns) or green (no concerns).

Monitor's financial risk ratings

When assessing financial risk, Monitor's ratings reflect the likelihood of an actual or potential financial breach of the FT's terms of authorisation. The ratings are based on four criteria: achievement of financial plan, underlying performance, financial efficiency, and liquidity. Financial risk ratings are allocated using a scorecard which compares key financial information across all FTs. A rating of five reflects the lowest level of financial risk and a rating of one the greatest.

If an NHS FT has failed to comply with the terms of its authorisation and this is significant–for example, if it consistently fails to meet required standards of care or is at significant financial risk–Monitor's board may decide to use its statutory powers of intervention. These range from closing a specific service, to removing any or all of the directors or governors and appointing replacements.

The risk manager's perspective

To get a better appreciation of how risk management operates in NHS trusts, the views of nine acute NHS trust risk managers were obtained via exploratory telephone interviews in 2010 and 2011. Eight of the nine trusts selected had recently achieved an increase in their CNST risk management level.

The main findings to emerge from these interviews were as follows:

• All trusts which achieved a risk management level increase claimed to have done so as part of a planned strategy–while this was mainly the responsibility of the risk management staff, other stakeholders, such as the board of directors and clinical staff, were also engaged.
• The declared motivations for seeking a risk management level increase involved both reputational and financial issues. From a reputational perspective, trusts see patient safety and quality benefits from obtaining higher risk management levels ‘…the push for level two was about reputation and how we looked as a trust’; ‘It was a priority at board level to get to level three … to demonstrate that the trust's safety and quality agenda was in place and was embedded across the trust’. From a financial perspective, as discussed above, the NHSLA provides discounts on a trust's CNST contribution in return for the achievement of higher risk management levels and such discounts act as an incentive, as evidence by one interviewee: ‘there also was the financial incentive–the 10% discount on the premium was substantial and this came at a time when financial pressures were starting to be considered’.
• Financial strength is seen as being important in order to obtain risk management level increases. Trusts that are in a position to commit financial resources to assist with an NHSLA assessment typically will do so, and find such investments to be more than justified if a successful outcome is obtained. Making such an investment is not felt to be a prerequisite to obtaining a risk management level increase but there is a general consensus that financially strong trusts are in a better position to do so as they have more resources to enable them to make such financial investments.
• Trusts with good governance structures believed that they were more likely to obtain risk management level increases. Eight of the nine trusts had recently increased their risk management level while all had recently acquired FT status. These tended to go hand in hand: one interviewee felt that trusts had to demonstrate good risk management arrangements as part of the process when applying for FT status, while another felt that a positive outcome of acquiring FT status was that it gave trusts a ‘good governance structure which helped when applying for risk management level increases’.
• The governance structures in place as a result of acquiring FT status are said to be enhancing the risk management function within trusts. The new structures in FTs include public interest governors, staff governors and representation from the trust board. While such arrangements have taken time to settle down, they now ‘work quite well and both public and staff governors are willing to support quality initiatives such as the patient experience’. From a financial perspective, FTs are also granted financial freedoms such as the ability to raise capital from both the public and private sectors within borrowing limits determined by projected cash flows–this is said to enhance the ability to invest in risk management level improvements.

In summary, the consensus of the views obtained from our interviews with risk managers implied that there are definite relationships between governance structures, financial health and risk management activities–trusts typically have a plethora of external organisations to deal with on an annual basis and improvements made in governance relationships (as evidenced by acquiring FT status) are typically accompanied by improvements in a trust's financial position, and this improved financial health is an enabler to help them improve their risk management practices.

The interdependence between governance, finance and risk management

From the views expressed by hospital risk managers, there would seem to be a strong a priori expectation that hospitals with good governance would perform well in relation to the management of clinical risks. Well run hospitals should have in place the structures to enable sound decisions about the allocation of resources, including those concerned with investment in patient safety measures. Moreover, hospitals with sound finances are expected to be best placed to manage clinical risk well; clearly, concerns about financial risks would be expected to constrain management in pursuing clinical risk management opportunities which require additional resources.

To confirm whether this expectation was borne out by the evidence, the extent to which the ratings described above were correlated with each other were explored. The following tables show the results obtained by comparing the ratings given to 137 foundation hospitals as at 30 June 2011, including the CNST risk management levels as assessed by the NHSLA and current at that date.

Tables 1 and ​ and2 2 show the relationship between the CNST risk management levels and Monitor's finance and governance risk ratings respectively. Surprisingly, there appears to be little correlation between these, and this is confirmed by the Chi-squared tests reported at the foot of each table. By contrast, Table 3 shows a significant relationship between Monitor's ratings for financial and governance risk. It seems that Monitor's separate assessments of hospitals' exposure to risk is correlated, but bears little relationship to the quality of clinical risk management measures as audited by the NHSLA.

CNST levels by finance ratings.

CNST levels by governance ratings.

Governance ratings by finance ratings.

Part of the explanation for this conundrum may lie with the way that the NHSLA incentivises hospital managers to improve their risk management levels. Discounts of up to 30% on the CNST contributions are available for hospitals assessed at the highest level. This could conceivably lead to mixed consequences: hospitals with good governance and low financial risk may feel that the extra expense involved in acquiring higher standards is justified, but on the other hand hospitals facing financial problems could also feel that the contribution discounts are a way of easing those problems. So the relationship between governance, finance and clinical risk may be a complex one.

To illustrate this, as part of a programme of research funded by the ESRC on public services quality, several studies exploring the link between the financial incentives for improved risk management and the responses by NHS hospitals were recently conducted. In one study, no relationship between the utilisation of diagnostic imaging tests and the risk management level attained was found. 6 However, in another a positive relationship between higher risk management levels and a lowering of the hospital's MRSA infection rate was found. 7 It has been speculated that certain types of patient care activity, including the use of diagnostic tests ordered by individual clinicians, may be less responsive to risk management incentives placed at the level of the hospital, whereas others, such as hospital infection control policies, are much more amenable to financial incentives at that level.

In this paper the reasons why good hospital governance and sound finances are expected to be conducive to improved clinical risk management processes and outcomes have been set out. These expectations were shared by those risk managers interviewed in NHS hospitals–they clearly believed that there was a causal connection between their governance structures, the quality of their financial risk management, and the NHSLA's assessment of their clinical risk management standards. In practice, the current evidence from FTs does not bear this out, at least in the strict sense of a correlation between measurements of risk management standards across these categories. Why should this be so? There are a number of possible explanations. The measurement of risk management standards by Monitor and/or the NHSLA may be flawed, or the measurement may be accurate but the expected relationships are not there–they could be based on rhetoric not reality. Alternatively, the notion of risk management is something far more complex than can be captured by a single number for each hospital. Complex organisations can suffer from considerable inefficiencies, not least in terms of communications and internal incentives. Harris addresses such points explicitly to hospitals. He argues that the hospital is ‘two firms in one’: a medical staff and an administration, each with ‘its own objectives, decision variables, and constraints’. 8 Attempts to incentivise one of these groups to the exclusion of the other may end in failure. This problem is not a new one, but the widening remit of risk management in NHS hospitals does beg the question: whose risk is being managed?