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Risk Management and Patient Safety

In the year 400 BC, the Greek physician Hippocrates said: “First, do no Harm” (First, do no harm) – the quote shows the importance of managing actions related to patients, so that events that cause harm can be avoided. In other words, there is always a “quid pro quo” (something for something). As models in risk management, we can mention high reliability industries (HRO), such as nuclear plants, semiconductor industries, chemical industries and aviation, which provide greater safety in their processes. An example is the safe surgery checklist, which was developed based on the aviation checklist model.

According to renowned psychiatrist James Reason, creator of the Swiss cheese theory, to explain failures, accidents, disasters and failures in complex systems, the impact of a failure depends on where it happens and barriers to prevent these errors must exist throughout the process. . And based on this, it is important to correctly manage risks and the environment, as they can influence the severity of the outcome.

According to professor Jens Rasmussen, also very influential in the field of safety science and human accidents, risk is a living and dynamic system that constantly changes according to changes in contexts and differences between levels of healthcare and organizational collaborators.

And, based on the influence of Organizational Culture, actions related to risk control are defined, promoting greater safety for patients and employees. A safety culture cannot be decreed but collectively constructed daily, in speeches and actions.

Some situations that deserve attention are:

• Definition of the most important risks and the conviction that they can change, thus requiring careful control;
• Recognition of teamwork, mobilization and knowledge of everyone;
• Balance between standard and action capable of anticipating facts and unforeseen events;
• The design of barriers in everyday life;
• Safe and proactive compliance through security in decisions, participatory management and debates between professionals;
• Trust and freedom of expression through fair culture, circulation of information, coherence of acts and speeches;
• Organizational human factors: people, their working conditions, work teams, organization and management.

A human error is a consequence of other defects in the organization, in 95% of cases.

In many industries, people simply do what they can to solve their daily problems. Without collaboration, and even breaking the rules, incidents would be more frequent.

Conclusion

Study the process, the means involved and the safety culture dominant, analyzes each part and uses tools to get to the root causes (Root cause analysis). Don't be superficial and act collectively. It is important to accept that the incident will happen and we must be prepared to avoid or mitigate the damage. Don't blame people's malice, as it has been shown to occur in less than 1% of incidents. Responsibility almost always involves management that must be modified. A company will be at fault if an accident occurs when this risk was measurable and remained ignored.

“We cannot change the human condition, but we can change the conditions under which we work to make mistakes less likely and easier to recover from if they do happen.” (James Reason).

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