Risk Assessment Procedure and Risk Register …

1 Risk Assessment Procedure and Risk Register guidance Date: January 2013 Version number: 2 Author: Catriona Oxley, Safety and Risk Manager Review Date: January 2015 If you would like this document in an alternative language or format, please contact Corporate Services on 01595 743069 HRSSPRO001 2 NHS SHETLAND DOCUMENT DEVELOPMENT COVERSHEET Name of document Risk Assessment Procedure and Risk Register guidance Registration Reference Number HRSSPRO001 New Review Author Catriona Oxley Executive Lead Lorraine Hall Proposed groups to present document to.

2 Risk Management Group Clinical Governance Co-ordinating Group Health and Safety Committee Risk Management Group Clinical Services Management Team DATE VERSION GROUP REASON OUTCOME 5 September 2012 2 (First draft) Risk Management Group PI & C/S MR & PRO 7 November 2012 2 (Second draft) Health and Safety Committee PO & C/S PRO 27 November 2012 2 (Second draft) Clinical Services Management Team PO & C/S MR & PRO 17 January 2013 (5 December 2012 meeting postponed) 2 (Final draft) Clinical Governance Co-ordinating Group PO & C/S PRO 31 January 2013 2 (Final draft) Risk Management Group Approval MR & Approved Examples of reasons for presenting to the group Examples of outcomes following meeting Professional input required re.

3 Content (PI) Significant changes to content required refer to Executive Lead for guidance (SC) Professional opinion on content (PO) To amend content & re-submit to group (AC&R) General comments/suggestions (C/S) For minor revisions ( format/layout) no need to re-submit to group (MR) For information only (FIO) Recommend proceeding to next stage (PRO) 3 DATE CHANGES MADE TO DOCUMENT 5 September 2012 Section 9 where it refers to Directorate Risk registers completed to reflect the current position and future plans Update of definitions of Adverse Incident and Significant Adverse Event/incident to dovetail with terminology used in Incident Reporting, Investigation and Management policy 27 November 2012 Noted by the CSMT that the risks associated with substances hazardous to health are assessed using the systems described in the separate document.

4 Procedure for the Control of Substances Hazardous to Health [COSHH]. This has been made clearer under Section 11 Following discussion on where the document should be signed off, it was agreed the paper should go back to RMG. 31 January 2013 Add the following sentence to Section 2, penultimate paragraph: It is not intended to be used for the clinical risk Assessment of individual patients care and treatment, however risks identified around an individual patient s care may be used to develop a departmental/directorate/corporate risk that would reduce the possibility of future incident.

5 4 TABLE OF CONTENTS 1. EXECUTIVE SUMMARY .. 5 2. INTRODUCTION AND LEGISLATIVE FRAMEWORK .. 5 3. THE PRINCIPLES OF RISK Assessment .. 6 4. DEFINITIONS .. 7 5. MONITORING AND REVIEW .. 8 6. COMPLIANCE .. 8 7. RISK Assessment .. 9 8. CONDUCTING A RISK Assessment .. 10 STEP 1: IDENTIFY THE HAZARDS .. 11 STEP 2: DECIDE WHO COULD BE HARMED .. 11 STEP 3: EVALUATE THE risks AND DECIDE ON PRECAUTIONS (CONTROL MEASURES) .. 12 STEP 4: RECORD YOUR FINDINGS AND IMPLEMENT THEM.

6 13 STEP 5: REVIEW YOUR Assessment AND UPDATE IF NECESSARY .. 15 9. RISK registers .. 15 10. ROLES AND RESPONSIBILITIES .. 16 11. FURTHER INFORMATION .. 18 12. EQUALITY AND DIVERSITY IMPACT Assessment [EDIA] .. 19 13. REFERENCES .. 19 14. APPENDICES .. 20 APPENDIX A NHS SCOTLAND CORE RISK Assessment MATRICES .. 20 5 1. Executive Summary Risk management in healthcare includes the whole spectrum of things that could and can go wrong. It includes slips, trips and falls involving staff, patients and the public, administrative errors that impact on patient care and clinical incidents that have a direct effect on the outcome of patient care.

7 It also includes the management of the business risks associated with running a NHS Board or hospital including financial, ethical and information technology risks 1. Risk Assessment is the method whereby hazards in the workplace are identified, quantified and managed and is a proactive process focused on the risks that really matter the ones with the potential to cause real harm 2. This document has been produced to provide practical guidance for all staff on risk Assessment techniques and the compilation of risk registers . The Procedure is based on the current Risk Management Strategy 2012 - 2015, underpinned by the Australia/New Zealand Risk Management Standard and incorporates guidance published by the Health and Safety Executive on risk Assessment .

8 2. Introduction and Legislative Framework The Healthcare Quality Strategy for NHSS cotland sets out three quality ambitions to support NHSS cotland to deliver the best quality healthcare to the people of Scotland. The second of these states: There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times 3. This ambition dovetails with the NHSS cotland Staff Governance Standard that requires all NHS Boards to demonstrate that staff are provided with a continuously improving and safe working environment, promoting the health and wellbeing of staff, patients and the wider community 4.

9 The Management of Health and Safety at Work Regulations [MHSWR] 1999 place an absolute duty on every employer to assess the risks to the health and safety of employees whilst they are at work5. This legal obligation also extends to cover the risks to the health and safety of people who are not employees but who might be affected by the work undertaken and/or the nature of the business. 1 NHS Scotland Clinical Governance 2 HSE (2006), p. 1 3 The Healthcare Quality Strategy for NHSS cotland, The Scottish Government, May 2010 4 The NHSS cotland Staff Governance Standard: 4th Edition, The Scottish Government, June 2012 5 MHSWR 1999, Section 3(1)(a) 6 Shetland NHS Board (the Board) recognises its duties under the Regulations and the purpose of this Procedure is to provide guidance for all staff on practical steps to assess and manage risks .

10 It forms an important part of the Board s Risk Management Strategy6, which aims to ensure that appropriate and effective systems and processes are in place to actively and systematically manage the risks to which the Board, its staff and service users are exposed. This Procedure is a proactive tool to help staff to predict and prevent adverse events (including near misses) thereby avoiding harm to the wide range of individuals and groups including patients, staff, visitors and the many others who use our premises and services. It is not intended to be used for the clinical risk Assessment of individual patients care and treatment, however risks identified around an individual patient s care may be used to develop a departmental/directorate/corporate risk that would reduce the possibility of future incident.