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SSA Toolkit

Identify risk


Identify risk

Identify risk

Identifying the things that could go wrong in the system

This section looks at how to identify potential problems in the system under examination. This is important as it is the first step to identifying the main risks which need to be addressed. To identify potential problems it is important to learn from any past problems and to consider the potential for new problems that have not occurred previously. Both topics should be considered when conducting an SSA on any existing system, but the latter is especially relevant when considering the risks in novel systems.

On this page:

Identify risk is the first activity in the Assess phase of SSA

Identify risk is an activity in the Assess phase of SSA

Identifying risks

It is now necessary to examine the question at the core of the SSA: ‘What could go wrong?’. To help answer this, it can be helpful to refer back to any maps or descriptions of the system created earlier in the Describe system activity. Since the aim of the SSA is to be systematic, try to find a logical starting point on the system map, and work through each of the items in turn. Usually, this will be the first task in the process map, or the first thing that needs to be communicated in a communication diagram. For each item in the map, ask what has gone wrong or could go wrong with that item.

Bear in mind that the more problems are identified, the more work there will be to fill in the Assessment Form completely.

The time constraints for completing the assessment need to be balanced against the need to identify risks comprehensively and accurately. Systems which involve higher risks (for example, when considering the risks involved in handling controlled drugs, or the treatment of very unwell patients) may require more effort. More complex systems will also require more analysis. If the SSA is running out of time, an additional meeting may need to be scheduled, or the scope of the assessment can be narrowed. Remember to write down what is and what is not assessed in the SSA in the Setting the scope section within the Outline goals activity.

Portion of a risk table, showing the things that could go wrong at some of the steps in the process. The first step is: Unit gets staff in place. This could go wrong by insufficient staff being available to accept patient. The next step is: Police and Young Person arrive at unit. This could go wrong by a Delay in getting staff in place, or No space in unit due to another patient already present. Another step is: Paperwork checked. This could go wrong by No or incorrect paperwork being available.

Examples of ways in which the parts of the system could go wrong

To aid thinking more widely about possible risks, it is helpful to learn from past problems as well as looking for new problems (both described further down on this page).

Putting ‘What could go wrong?’ into practice

Space to record this information is provided in the SSA Assessment Form. To do this:

  1. Select the ‘Identify/Analyse/Evaluate risks’ page in the Assessment Form.
  2. Leave the first column (ID) blank for the moment.
  3. Enter the parts of the system in the second column (headed What is going on?). Describe each part on a separate row. Referring back to the map(s) on the ‘System maps’ page may help.
  4. For each part of the system, enter ways in which it could go wrong in the next column (What could go wrong?). If one part could go wrong in multiple ways, use several rows to describe the different situations. New rows can be added by highlighting the row below the relevant one, right clicking and selecting Insert.
Screenshot of the Risks page of the assessment form


Case Study

Part of the completed ‘Identify/Analyse/Evaluate risks’ page from the Section 136 case study is shown opposite. Further explanation of this stage in the case study can be found on the Section 136 page about Identifying risks.

Learning from past problems

When assessing an existing system, it is important to consider what has already gone wrong. This is also often helpful when examining a new system that is similar to an existing one. If the system is entirely new, it may be more helpful to skip to looking for new problems (below).

There are two main avenues that can build an understanding of past problems:

  • Consulting historical sources of data, such as incident reports and meeting minutes. Existing risk assessments (if available) can also be useful in highlighting issues to consider.
  • Talking to people with experience of the system. These people could be interviewed or could be involved more directly in SSA meetings, perhaps using techniques for engaging stakeholders in the SSA.

Looking for new problems

When assessing both existing and new systems, it is important to consider potential future problems, which may differ from problems that occurred in the past. There are various methods than can help to do this:

  • Conducting a site walk-around. If the system is already in existence or there is another similar system, then a site walk-around can be useful to prompt ideas on what else could go wrong.
  • Examining maps and descriptions of the system, such as those produced in the Describe system activity. It is important to think through what problems might occur in a systematic manner. Stakeholders should be given the time to brainstorm plausible possibilities. It is only necessary to record ‘reasonable’ possibilities - aliens from Mars abducting patients is (at the time of writing) very unlikely indeed.
A portion of a process diagram, showing the steps: Unit gets staff in place, Police and YP arrive, Paperwork checked, YP waits for assessment.

It can be helpful to examine each of the steps in the process diagram in turn to see how they could go wrong.