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SSA Toolkit

Propose actions

 

Propose actions

Propose actions

Proposing ways to address the risks that are too high

This section looks at how to propose ways to reduce risks that are unacceptable. It outlines a range of different risk reduction methods and advocates identifying a number of possible actions and then comparing their effectiveness. This is important because it encourages a wider range of ideas and actions, and generally leads to a better solution and subsequent outcome. Understanding and challenging the assumptions behind suggested actions, and combining elements of different actions may also lead to better outcomes being delivered.

On this page:

Propose actions is the first activity in the Improve phase of SSA

Propose actions is an activity in the Improve phase of SSA


Generating ideas for actions

At this point, it is important to produce some Ideas of actions that could reduce the risks. This is particularly important for those risks that were identified as requiring action in the Assess phase (typically coloured Red or Orange). For each risk it is helpful to look back and examine the underlying problem, impact and likelihood. Understanding where the risk came from can help to determine how to reduce it.

The chance of finding suitable actions can also be increased by considering a range of risk reduction methods. Examples of these are described later on this page, grouped into five categories. Each of the categories should be worked through in turn, choosing at least one method from each category to identify possible actions. At this stage, the quality of the ideas is not especially important, as even poor quality ideas may stimulate others that are better.

 

Portion of table of proposed actions, divided into five different types of actions. Risk B is the knock-on effect of pulling of staff from other areas of the unit to accept a patient at times of high activity in the unit. Proposed actions for dealing with this include Stop offering the 136 service, and never take staff from other areas to cover the Suite. These are both examples of Removal of high-risk processes. Examples of Design controls include use automated processes to help assess young people, and locate the unit closer to the staffing area to reduce journey time. Examples of Administrative measures include review the staffing policy and implement changes, and improve staff training to help speed up the assessment process. Examples of Monitoring include use CCTV, and give waiting young people a self-report mood tool and monitoring the results. The last type of action is Preparation for foreseeable risks. Examples of this include develop plans to manage an escalating situation, and train staff on de-escalation techniques.

Examples of proposed actions for the risks involved with a protracted wait for assessment. Risk B is the knock-on effect of pulling staff from other areas of the unit to accept a patient at times of high activity in the unit. Risk C is a delay in getting the staff in place. (Click to enlarge)

 

After generating some ideas for possible actions, it can be useful to go back through them, reviewing and modifying them as necessary. The ideas can also be combined to create stronger, more effective solutions.

Putting ‘Generating ideas for actions’ into practice

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

  1. Select the ‘Identify/Assess/Evaluate risks’ page in the Assessment Form.
  2. Examine the risk scores and colour bands in column J (headed What is the risk?) and identify which risks require reduction. Take note of their ID numbers (from the first column in the table).
  3. Select the ‘Propose actions’ page.
  4. Enter the ID numbers of the risks that need to be reduced in the first column of the table (headed ID).
  5. For each of these risks, enter ideas for reducing it in the columns on the right. Each column corresponds to a different type of risk reduction method. Try to include a variety of ideas, using all of the columns. Describe the ideas briefly - details can follow later.
  6. Follow this process again for any other risks that require reduction. New rows can be added if needed.
Screenshot of the Risks page of the assessment form

 

Screenshot of the Propose actions page of the assessment form


Case Study

Part of the completed ‘Propose actions’ 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 Generating ideas for actions.


Categorising risk reduction methods

It is necessary to consider a range of risk reduction methods in order to generate a strong pool of options to choose from. Five categories of methods are listed below, with additional details and examples presented further down this page. This is not an exhaustive list, but represents some of the different perspectives. Not all of the methods will apply to every situation, but they are helpful in thinking through a range of possibilities. They are listed in order of likely preference, with the (typically) most effective methods placed first:

  1. Removing high-risk processes may involve replacing a high-risk process with a lower-risk one, transferring the risk to another group or organisation, or simply not using the existing process or materials;
  2. Implementing design controls may involve careful design of equipment or buildings, for example, using physical barriers to limit access to risky areas or making important equipment easier to use and correspondingly harder to misuse;
  3. Defining administrative measures may involve creating procedures, training or signs, to encourage people to take the correct actions;
  4. Monitoring for problems may involve observation or the use of alarms to detect when something is going wrong or is likely to do so, in time to reduce its impact or prevent it altogether;
  5. Preparing for foreseeable risks may involve having a plan, effective training and appropriate resources available to reduce the impact of the risks when they occur.

In addition, when choosing a method, it is important to take account of the nature of the risks present in the system.

More help in identifying and analysing different kinds of methods for addressing risk is provided in The Active Risk Control (ARC) Toolkit, available in the Resources section of this website. Whilst the ARC Toolkit represents a ‘gold standard’, and may be suitable for some SSAs, much of the content has been reproduced in a simplified form in the following sections.


1: Removing high-risk processes

One method of reducing risk is to remove the risky process or materials. This can be achieved in various ways by:

a) Replacing the process with a lower-risk one. For example, some Trusts have opted to only administer one of two available strengths of particular high-risk tablets to patients, in order to reduce the risk of confusion inherent when administering a combination of doses.

b) Transferring the risk to another group or organisation that may be better placed to cope with it. When using this option, it is important to ensure that the transfer is acceptable to all parties. For example, the risk of high-risk drug preparation can be transferred from the ward to the pharmacy.

c) Avoiding the use of the dangerous process or materials. For example, a low-volume specialised surgical unit might be closed, where surgeons are not getting enough practice to maintain their surgical skills. It might then be replaced with a national centre.

Photograph of a yellow tablet marked with the numbers 2.5

 

Some Trusts have opted to only administer 2.5mg methotrexate tablets to patients, after serious harm occurred due to confusion regarding 2.5mg and 10mg tablets

Putting ‘1: Removing high-risk processes’ into practice

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

  1. Select the ‘Propose actions’ page in the Assessment Form.
  2. Enter ideas in column D (1 Removal of high-risk processes). Use a separate line for each idea.
Screenshot of the Propose actions page of the assessment form

2: Implementing design controls

Another method of reducing risk is to design the equipment or buildings carefully to make it harder for people to make a mistake or to complete a high-risk action. This can be achieved in various ways by:

a) Adding barriers to limit access to high-risk areas.
For example, locked medicine cabinets can be used for storing controlled drugs, or barriers can be added to software to prevent ordering dosages above a certain amount.

b) Isolating patients, processes or equipment.
For example, separate rooms might be provided for patients with particular types of communicable diseases.

c) Automating processes that are susceptible to human error.
For example, drug retrieval in a hospital pharmacy can be automated.

d) Improving the usability of equipment and services.
For example, low-lighting might be added around ward bays to help patients to get safely to the toilet at night, or the layout of a resuscitation trolley might be changed to make it easier to find key materials (more information can be found on the RCA's website).

e) Adopting failsafe / mistake proof design.
For example, oxygen connectors could be used in anaesthetic machines that cannot physically be connected to anaesthetic gas lines.

The new design of the resuscitation trolley. The equipment is laid out to allow easy acess, and the trolley can divide into three separate units, with the kit needed by different team members.

The Resus-station is a redesign of the resuscitation trolley to reduce errors and better match the needs of the resuscitation team (Image reproduced by the kind permission of the Royal College of Art)

Putting ‘2: Implementing design controls’ into practice

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

  1. Select the ‘Propose actions’ page in the Assessment Form.
  2. Enter ideas in column E (2 Design controls). Use a separate line for each idea.
Screenshot of the Propose actions page of the assessment form

3: Defining administrative measures

A third method of reducing risk is to use administrative measures. In fact, these tend to be by far the most frequently used methods to reduce risk in healthcare. Policies, procedures, training, signs and other measures can be used to help people take correct actions, but ultimately safety will still depend on people doing the right things. A variety of administrative measures can be used, such as:

a) Implementing new or revised policies and procedures to encourage less risky behaviour or forbid particularly high-risk actions.

b) Providing checklists, signs, quick reference guides and other memory aids to help people to know the correct actions to take.

c) Introducing double checking measures, which require double confirmation on high-risk functions.

d) Using partial automation.
For example, whilst not actually preventing a mis-prescription, prescribing software may display reminders of high-risk drug interactions when a drug is being prescribed.

e) Issuing alerts or running awareness and persuasion campaigns to raise awareness of patient safety issues.

f) Providing training and education where there is a genuine and clearly-defined training requirement and sufficient funding is available to ensure that the programme is delivered with an appropriate level of quality.

g) Introducing more rest periods to reduce tiredness and stress in staff.

A screenshot of prescribing software, displaying an alert when Methotrexate is being prescribed. The alert reads: Cytotoxic Drug: BNF recommends specialist literature be consulted.

Prescribing software may issue an alert when a high-risk drug is prescribed

Putting ‘3: Defining administrative measures’ into practice

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

  1. Select the ‘Propose actions’ page in the Assessment Form.
  2. Enter ideas in column F (3 Administrative measures). Use a separate line for each idea.
Screenshot of the Propose actions page of the assessment form

4: Monitoring for problems

Another method of reducing risk is to use monitoring to detect when something is going wrong, or is likely to go wrong, in time to reduce its impact or prevent it altogether. This can be achieved in various ways, by:

a) Introducing or strengthening observation of the situation.
For example, the frequency of nursing observations might be increased or CCTV cameras might be used in areas of higher security risk.

b) Setting alarms.
For example, clinical alarms can be used when monitoring particular patient parameters. In the East of England, drugs trolleys are being trialled with a built-in alarm that sounds when it is left unattended and insecure during ward rounds.

c) Asking patients to alert staff if specific signs or symptoms occur.
For example, patients undergoing chemotherapy may be told to inform staff if experiencing a temperature of greater than 38°C.

d) Monitoring the system through auditing, surveys, incident reports, and ‘near-miss’ reports for adverse incidents that did not cause harm, but had the potential to do so.

Image of an incident report form. It includes fields such as date, time, injured person's name, details of incident, injury type, whether the injury required a hospital, signatures and important notes and instructions.

Example of a form for reporting an incident

Putting ‘4: Detection of issues’ into practice

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

  1. Select the ‘Propose actions’ page in the Assessment Form.
  2. Enter ideas in column G (4 Detection of issues). Use a separate line for each idea.
Screenshot of the Propose actions page of the assessment form

5: Preparing for foreseeable risks

A fifth method of reducing risk is to be prepared for predictable risks, so that when they do happen they have less of an impact. It means having a plan, as well as effective training and appropriate resources available to implement that plan. This can be achieved in various ways, by:

a) Preparing resources in advance to deal with the problem if it happens.
For example, efforts may be made to ensure that matching blood is readily available for surgery where major blood loss is likely.

b) Developing emergency operations / response plans, which detail the response to adverse events.
For example, plans can be created for the response to being exposed to a dangerous virus in the emergency department, or evacuation plans can be put in place for a hospital in the event of a severe fire.

c) Testing equipment before use.
For example, routine tests may be conducted annually (such as Portable Appliance Testing for electrical equipment), or emergency resuscitation equipment may be tested each time just prior to its use.

d) Training personnel to carry out important functions during an emergency.

e) Using protective equipment in dangerous environments.

A photograph of the setup for fire safety training, with cart and fire extinguishers

University of Cambridge fire safety training is an example of preparing for foreseeable risks

Putting ‘5: Preparing for foreseeable risks’ into practice

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

  1. Select the ‘Propose actions’ page in the Assessment Form.
  2. Enter ideas in column H (5 Preparation for foreseeable risks). Use a separate line for each idea.
Screenshot of the Propose actions page of the assessment form