Risk Assessment

• do not have tragic consequences for the affected parties
• although not defined as serious, may highlight significant risk potential for a local health provider, including loss of public confidence, loss of ability to provide a service and adverse publicity

Within the health economy there is clear value in 'taking a second look' at all incidents that do not result in severe harm, as part of the overall safety and quality improvement process. Using a risk assessment tool can help provide a structured management framework to evaluate each incident and assign clear accountability for actions and learning, post event. Colour coding each incident provides clear, unambiguous guidance on the severity and escalation requirements for each incident.

The colour coded risk assessment tool
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History
Maria Dineen, Director of Consequence, developed the colour coded risk assessment tool in response to the growing need to manage the increasing volume of incident investigations. The tool provides a clear route in the incident reporting process to identifying priority events, assigning responsibilities and resultant actions.

Based on a similar model used by Exxon Chemicals in 1998, Maria developed the tool and initially established three incident grades:

Green - minor, no harm event or near miss, requires no follow-up
Yellow - moderate event or near miss, requires local management action
Red - significant event or near miss, requires senior management attention

She later evolved the tool, incorporating an 'Orange' grade, to signify events that, although not requiring follow up by senior executive management, should be subjected to a significant event review and monitored by the relevant local management teams.

Today, those using the tool ensure that Orange and Red events are monitored by risk management committees and learning outcomes are evaluated via the local clinical governance framework.

Maria Dineen has continued to refine the colour risk matrix and in 2002 added a fifth colour - Crimson - to assist in absolute clarification of the highest risk events.

Why colour?
There has been historical interest in colour psychology across many industries and disciplines. In 1969 Max Luscher (the Lusher Colour Test - New York, 1969) undertook detailed research to establish the 'clearest possible relationship between colour as a phenomena and the psychological effects corresponding to them. Before him, Heiss and Halder had introduced the Colour Pyramid Test.

At the core of the original tool is the belief, by its creator, Maria Dineen, that colour is the easiest medium for potential users to relate to. This belief has been confirmed by interest generated in the tool both within the UK and in the international healthcare arena, since its introduction at an international symposium in Dublin in 2000. Today, practitioners as far afield as Australia have been inspired to use colour for risk assessing adverse events.

Colour grade definitions
Red is one of the four psychological colours. Physically stimulating, it is universally used around the world to represent danger or excitement. In this tool, Red and Crimson are used to denote the most serious incidents, and near miss events.

Orange or amber is frequently used as an 'alert' or 'warning' colour and is used in this tool to identify those incidents that, whilst not 'tragic' or 'catastrophic', imply increased risk and therefore worthy of attention. In their research into colour coding for complex data analysis in 1996, Edward Gould and Irina Verenikina found the most commonly selected colours to represent the notion of increasing risk were Orange and Red.

Yellow is considered to be a colour that supports optimism and creativity. In the spectrum of colours used in the risk assessment tool, it represents a low risk event that offers scope for valuable local learning.

Green is at the centre of the colour spectrum and requires no adjustment to view. It is used to represent the lowest grade of event. Incidents falling into this category are not considered to pose any real threat to person or property either now or in the future. These incidents require no follow up, other than that deemed necessary by the local team.

A proven methodology for risk assessment
Between 1999 and 2000, ten NHS Trusts agreed to participate in an evaluative research project to explore the effectiveness of a structured process in assessing the severity of adverse events and near miss events, using colour.
These Trusts found the colour risk assessment tool:

• enabled them to develop a more systematic approach
• increased management's awareness of the significance of a range of incidents
• was 'user friendly' and simple to apply for staff involved in assessing incidents
• helped prioritise those incidents that required a deeper review or investigation
• enhanced the movement from 'blame culture' to a more systems based review of serious incidents
• resulted in a more consistent notification of serious incidents (and in particular 'near misses)

The National Patient Safety Agency's findings were similar at its pilot sites, where it found that using a structured risk matrix to specifically grade incidents:

• encouraged exploration of wider issues
• resulted in a better assessment of 'near miss' events
• increased objectivity and consensus

One of the most powerful comments made about the tool is:
"Incidents that are minor but have the potential to be major have been investigated more thoroughly."

The advantages of introducing a risk assessment system
Instituting a systematic approach to the risk assessment of incidents that do not result in tragic harm (life long injury or death) delivers significant benefits. It enables:

• organisations to introduce clearly defined levels of accountability for action and learning from adverse events
• the identification of potential future disasters'
• the exploration of quality and safety failures before anyone is hurt
• the development of a safety culture
• local teams and organisations can demonstrate 'due process' in their decision making
• the introduction of qualitative analysis within the incident management process
• the systematic determination of which events deserve closer review

Introducing risk assessment of incidents - the challenges
There can be a number of issues that impede the introduction of a rigorous process for the risk assessment of incidents. There is a tendency to ignore the circumstances and context of an incident, which can result in the false upgrade or down grade of events, for example, a patient fall. As well the risk of 'rigging' an assessment outcome for political gain, there is the temptation of 'down grading' to avoid the time consuming investigation process of any event. In addition, local departments can become reliant on central groups investigating, rather than taking ownership of localised events.

A two dimensional model of risk assessment may only focus on impact to the individual without considering the broader implications and any emphasis on the quantitative reliability of the assessment can result in no action being taken.

All these challenges can be overcome through the evolvement of safety culture and introduction of a clear framework of incident management:

• individuals who risk-assess incidents are trained to do so, and understand its purpose
• local governance performance monitoring systems assess the appropriateness of a sample of risk assessments via a peer review process or local appraisal process
• those who receive notification of code Orange and Red incidents review the appropriateness of the grading and liaise with originators to:
  1. review any disagreement of the assessment and why an event was so scored
  2. come to a consensus with the 'originator' on such occasions
• risk managers do not minimise the significance of events to a local speciality, or team
• the emphasis of incident reporting systems and policies moves from getting incident form from A to B, to focus on the learning outcomes of the event

The Risk Assessment process - as easy as ABC

A Impact evaluation
The first stage of the process is to determine the impact of the incident on people or property in terms of actual harm or damage caused. When the actual impact of the event is not immediately obvious, as with instances of psychological harm, categorising the outcome is a subjective process, dependent on the experience and knowledge of the person making the judgement.

Whilst staff can become overly concerned about the accuracy of their immediate risk assessment, particularly when 'impact' is not clear or obvious, there is always the option to upgrade or downgrade the initial assessment as the incident impact becomes clearer.

The goal here is to achieve a greater degree of consistency in the review of adverse events and to define clearly where responsibility for management and learning lies.

B Non-critical events investigation
Incidents that result in less than major or catastrophic harm (that is all non-Red events) should undergo a second tier of risk assessment to ascertain the future potential for each incident in terms of damage or harm in three key areas:

• on patients, staff or visitors should a similar event occur in the future
• for the organisation, in terms of loss of reputation, complaint, loss of resource, loss of confidence by staff or patients
• the scope, or spread, of the damage

Near miss incidents represent opportunities to identify safety and quality improvements and to assess the likelihood of the event recurring.

C Mapping decisions on the colour risk matrix
The Risk Matrix can be downloaded and adapted to your own local organisational needs and used, simply and quickly, to assess the risk score of an event or near miss. This provides a realistic and balanced view of the risk exposure associated with any individual incident.

This matrix differs slightly from AS/NZ 360:1999 because it pre-dates this tool's arrival in the UK. In addition, it was designed specifically for incident management rather than proactive risk assessment and organisational risk profiling.

The layout can be altered to mirror that of AS/NZ 4360:1999 and this is easy to achieve. The author of this tool prefers working from left to right with increasing risk.

Our request
We value any feedback on how well the tool works for you. Your comments will aid future development and evolution of the tool and your experiences may prove valuable to others. When using or adapting the colour matrix, we would be grateful if you could acknowledge the original source of the tool.

enquiries@consequence.org.uk
tel +44 (0)1865 741 044
fax +44 (0)1865 424 614

Consequence
18, Mark Road
Oxford
OX3 8PA
United Kingdom

Copyright 2003 Consequence