National Patient Safety Agency (NPSA)

Risk management and patient safety:

Risk can be defined as “the possibility of incurring misfortune or loss” and may be accompanied with patients, staff and visitors, equipment, consumables, buildings, system and management. Risk management is a proactive approach, which aims to identify, assess and prioritise risk on an ongoing basis, so as to minimise its negative consequence. (Risk Management Strategy, 2007). Risk management involves identifying the factors that may go wrong, influencing factors, to ensure action to prevent recurrence and restabilising the system is place to reduce risk.

Adverse events are a common phenomenon in clinical practice inspite of increased attention to quality. The root causes of adverse events lie in several

In 1999, all the Chief Executives of healthcare organizations were given a framework and statutory duty called clinical governance for management of healthcare service delivery, risk management, maintain quality and safety. In 2001, the National Patient Safety Agency (NPSA) was set up which was charged with a national reporting and learning agency for adverse events, to take lessons from reports and develop solutions to considerably reduce risk and prevent further recurrences. Safety alerts are been issued on various topics related to adverse events in all hospitals. NPSA has been working towards to change the culture from one of blame to one which is fair and open. This has been achieved by providing training to staffs in NHS institutions in conducting analysis of root cause in cases of adverse events. In UK, a charitable foundation called Health Foundation has been funding “Safer Patients Initiative” programme which works towards the improvement of quality of healthcare service across the continent (Burnett & Vincent, 2007). The NHS Quality Improvement Scotland (NHS QIS) clinical governance and risk management standards came into effect from Nov 2005. Steps for risk management strategy included establishing context, identifying risk, analysing risk, evaluating risk and treating risk along with periodic monitoring and

Woolf et. al and Grimshaw et. al suggests that utmost benefit that could be attained by clinical guidelines is to improve health outcomes. (Woolf, Grol, Hutchinson, Eccles, & Grimshaw, 1999). Clinical guidelines that provides correct information about the proven benefits of intervention and discourage the harmful or ineffective ones can be instrumental in reducing morbidity and mortality and improve the quality of life. (Grimshaw & Russell, 1993). Clinical guidelines can be very useful in improving the quality of clinical decision making. They can provide explicit recommendations for clinicians who are unclear about how to proceed or in deciding treatment options (Starey,