1. Risk Management
Tamer Gharaiybah, RN, MSN
Risk Management and Patient Safety Coordinator
Al-Ahsa Hospital
CQI Department

2. Objective
• To define risk management
• To classify type of risk
• To Clarify the process of risk management.
• To Explain risk assessment
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3.  types of risks
• Clinical Risk is any issue that may have an impact on the achievement of high
quality, safe and effective care for patients.
• Non Clinical Risk is any issue that may have an impact on the achievement of
hospital operation.
• Financial Risk is any issue that may have an impact on financial objectives.
• Risk management: a process includes identifying, assessing risks, and then
responding to risks.
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4.  Goals
 Decrease severity and number of Staff, patient and visitor injuries.
prepare an action plan to prevent harm or injury due to risks
Receiving and reviewing incident and occurrence reports
Improve communications among care givers
Implement and monitor compliance with the international patient safety goals
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5.  Goals,,,,
Assure that documentation of care is adequate
working closely with medical record committee
educating medical staff and employees on proper documentation procedures
avoid the use of unacceptable abbreviations that may lead to
misinterpretations
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6.  Risk Management Priorities for 2016
• Better tracking of incidents reports to learn from errors and improve
processes.
• Facilitating a culture of safety
• Facilitating a non-punitive culture to enhance the free reporting of errors by
the staff
• Promoting opportunities for patients/family participation and feedback in
their care processes
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7.  Risk Management Process
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Organizational objective
Identify the
risk
Assess the
risk
Manage the
risk
Report risk
Oversight, Coordination and
Monitoring

8.  Identify health risk
• Occurrence Variance Report is considered the best way to identify the risk.
• Identify type of hazards
 Chemical hazards
 Biological hazards
 Physical hazards
 Ergonomic hazards
• Best practice
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9.  Assess the risk
• To establish Risk Rating multiply “Likelihood” by the “Severity”.
• “Likelihood” means the probably of an event occurring.
• “Severity” means the degree of injury that can occur.
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10.  Probability (1 to 4)
• 1) Most unlikely: less than 1% chance of being experimental by an individual
during working life.
• 2) unlikely: experience once during the working time.
• 3) likely: experience once every 5 years.
• 4) Very likely: experience once during the last 6 months.
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11.  Severity (1 to 4)
• 1) trivial injury
• 2) slight injury.
• 3) serious injury.
• 4) most serious injury.
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12. Likeability
4 4 8 12 16
3 3 6 9 12
2 2 4 6 8
1 1 2 3 4
1 2 3 4
Severity
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extreme high risk
High risk
Moderate risk
Minimal risk

13. rate Description Required Action
1-2 Low
Acceptable: Unlikely to require specific application of recourses. Manage by routine
procedures. Monitor and review
3-4
Moderate Acceptable: unlikely to cause much damage or threaten the efficiency and
effectiveness the activity. Treatment plans to be developed and implemented by
operational leaders.
5-8
High Generally not accepted. Likely to cause some damage. Treatment plan to be
developed and reported to director
9-16
Extreme Not acceptable. Likely to threaten the survival or continued effective functioning of
the activity. Must be managed by directors.
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14. Example of clinical health risk management
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Activity
Identify the
Hazard
How
Who
might be
harmed
Contrast Media 1. Medication
error
2. Adverse
Drug Reaction
1. Error may occur due to Sound like and Look Alike contrast media.
2. Adverse Drug Reaction to Contrast Media might occur if patient not properly
assessed Patient
Environment Fire Hazard Radiology Machines (eg; X-rays, CT, DEXA, Mammo. etc) uses a very high
electrical current to produce Radiation which is at high risk for fire
1. Patients
2. Visitors
3. Staffs
4. Facility
Infection Control Staffs &
Patients may
acquire
Healthcare
Associated
Infection
1. Radiology Staffs have a high risks of acquiring Healthcare Associated Infection
due to their direct contact with the patients
2. Radiology Staffs are not oriented or not implementing proper Infection Control
Standards
3. All Patient Use Equipment and the Environment if not disinfected frequently
or as needed may cause the spread and acquisition of Healthcare Associated
Infection.
1. Staffs
2. Patient

15. CQI Departemnt 15
Activity Identify the Hazard How
Who
might be
harmed
Radiology
Reporting
Delays in medical
interventions for the
patient due to late
radiology report
the timeliness and turnaround time are not monitored.
patient
examination
and
procedures
. Radiation hazard
(Carcinogenic, DNA/
Cells Injury
1. Radiation is an electromagnetic energy that can penetrate or absorbed by the
human body and over exposure to it is harmful that can cause cancer.
(reference to https://en.wikipedia.org/wiki/Electromagnetic_radiation)
2. Patients have the risks to over exposure thru repetition of x-rays and not
providing radiation shielding.
Staffs working in Radiation emitting equipment have the risks of over-
exposures to the harmful effect of radiation when not properly oriented
3. Patients
2. Staffs
3. Visitors
MRI Serious Injury or Fatal
and Equipment
Breakdown
1. MRI uses a very powerful magnet to visualize human anatomy and patients
with pacemaker or any metallic object/s can cause serious injury or worse case
might be fatal.
2. Staffs working in MRI have the risks of danger if not properly oriented.
(RAD/HK/BMS/Security/Others.
1. Patients
2. Visitors
3. Staffs

16. CQI Departemnt
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Risk Likelihood Severity RPN Priority
Radiology Reporting 4 3 12 1
Radiation Hazard
2 4 8 2
Contrast Media
2 3 6 3
Equipment Malfunction
3 2 6 4
Infection Control 2 2 4 5
Environment 2 2 4 6
MRI Hazard
1 3 3 7

17. Hazard action required Responsibilities Target Date Action
Radiology Reporting 1. Assign individuals to monitor report
turnaround time.
2. Schedule an In-Service Training to all
radiologist regarding panic value reporting
and consultation.
1. Dr. Ashraf Abd El Hady
2. Dr. Hassan Rabie
3. Mr. Danny
4. Mr. Tamer
July 2016
1. Log sheet has been made to
monitor the timeliness of
radiology reporting and
assigned individuals to
monitor.
2. Project will be initiated for
this purpose to improved
Radiology Timeliness and
Turnaround Time using
FOCUS PDCA
radiation Hazard 1. Staffs Radiation Monitoring TLD’s has
been sent to the vendor for reading to
monitor staff radiation absorbed dose.
2. A mandatory radiation protection and
safety in-service training shall be scheduled
to all staffs working in Radiation Area.
1.Mr. Omran Ghanam
Purchasing Supervisor
2. Mr. Danny Salunga
July 2016
1. Re-Orientation for
Radiation Protection and
Safety to all staffs working in
Radiation Area
Contrast Media
1.Schedule Staffs Orientation and
Continuing Education
2. Separate Sound Alike Contrast Media
1.Mr. Danny Salunga August 2016
1. Invite Dra. Reham or
Dra. Areej to make an In-
Service for Sound Alike
and Look Alike
Medications
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18. Hazard action required Responsibilities Target Date Action
Electrical & Fire Hazard
(environmental)
1. Need to contact the vendor to update and
performed planned preventive maintenance of all
radiological equipment
1.Mr. Kemmannu
2.Mr. Danny Salunga
August 2016
1. Radiology Walk Around to focus
on Electrical & Fire Hazard together
with the Safety Officer and the
Environment of Care Committee
Representative
Infection Control
1. Orientation to newly hired Staffs shall be
mandatory.
2. Continuous In-Service Training for Staffs at least
annually or as needed.
3. Conduct frequent monitoring of staffs if they are
implementing proper Infection Control Standards,
Policies and Procedures.
4. Include Infection Control in the daily Total Quality
Management Rounds with checklist and action plans.
1. Mr. Danny Salunga
(Radiology Supervisor)
2. Ms. Remya Gopi
(I.C. Coordinator)
3. Ms. Nisha Shetty
(Radiology I.C.
Coordinator)
May 2016
1. All radiology Staffs should attend
the annual mandatory lecture for
this purpose.
2. Invite Infection Control
Coordinator to make an in-service
training to all radiology staffs
specific to radiology services.
3. Infection Control Checklist has
been added to Radiology Total
Quality Management Checklist
Contrast Media
1.Schedule Staffs Orientation and Continuing
Education
2. Separate Sound Alike Contrast Media
1.Mr. Danny Salunga August 2016 1. Invite Dra. Reham or Dra. Areej
to make an In-Service for Sound
Alike and Look Alike Medications
MRI Hazard
1. Conduct the Annual Mandatory MRI Safety
Education to all Radiology staffs, Housekeeping and
to Maintenance that might be assigned to MRI
1. Mr. Danny Salunga
2. Mr. Ahmed Rida
Support Services Director
1. Housekeeping
Supervisor
1. Mr. Emad Al Momattan
2. CME Coordinator for
Nurses and Medical Staffs
May 2016
1. An annual mandatory in-service
MRI Safety Training shall be made
for all staffs that have the
possibilities to enter the MRI unit
(eg; Radiology Staffs,
Housekeeping,
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