Criterion QI3.1 – Managing clinical risks

Why this is important

Patient safety incidents in clinical care occur in all health settings. Incidents that cause harm are referred to as ‘adverse events’.¹⁰ Those that had the potential to cause harm, but did not, are referred to as ‘near misses’.

If the practice does not make improvements after identifying an incident that resulted in a near miss or an adverse event, patients may be exposed to avoidable future adverse events and the practice team may increase their risk of medico-legal action.

If you use systems to recognise and analyse near misses and adverse events, you can identify, implement, and test solutions to prevent them happening again.
This includes having systems and processes in place to support infection prevention and control.

Meeting this Criterion

Most practitioners and practices already manage clinical risk on a daily basis. Many have informal and ad hoc methods aimed at preventing near misses and adverse events.

To reduce near misses and adverse events, you could:

• establish a system so that practitioners talk to trusted peers and supervisors for advice
• use a formal process of discussing within the practice what went wrong and how to reduce the likelihood of it happening again
• use structured techniques to analyse the causes of near misses and adverse events to reduce the likelihood of recurrence
• establish a system so that members of the practice team know how and to whom to report a near miss or adverse event, and that they can do so without fear of recrimination
• keep copies of the practice’s risk or critical incident register
• monitor the effectiveness of systems and processes for infection prevention and control (eg standard precautions)
• implement a clinical governance framework to help achieve a balance of ‘find it’, ‘fix it’ and ‘confirm it’ functions in order to improve the quality and safety of care
  • find it – use tools such as clinical audits and performance indicators to identify where quality improvement programs could improve the quality of care and patient health outcomes
  • fix it – after identifying where improvements can be made, implement strategies to address the issue
  • confirm it – measure the outcomes of the improvement using an effective evaluation process.

You may want to have your medical defence insurer check and approve your process for recording and responding to near misses and adverse events.

To reduce near misses and adverse events during periods of crisis, emergency or disaster, your practice must ensure that it has appropriate systems in place to receive relevant public health notifications. You must also ensure that the information is distributed to all practice team members in a timely manner.

Practitioners are increasingly referred to as the ‘second victims’ of adverse events because they can often feel that they have failed the patient,¹¹ which can lead to them second-guessing their clinical judgement and knowledge. You could therefore consider how to support practitioners after an adverse event has occurred.

Meeting each Indicator

QI3.1 A Our practice monitors, identifies, responds to and reports near misses and adverse events in clinical care.

You must:

You could:

• implement and maintain a clinical risk management policy
• conduct clinical audits
• make and document changes to reduce the risk of identified issues and to prevent adverse outcomes
• keep a record of team meetings and planning meetings where risks are discussed.

QI3.1 B Our practice team makes improvements to our clinical risk management systems in order to prevent near misses and adverse events in clinical care.

You must:

You could:

• record revisions to policies and procedures that have been shown to reduce risk.