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Introduction
The colour coded risk assessment tool
Why colour?
A
proven methodology for risk assessment
The advantages of introducing
a risk assessment system
Introducing risk assessment
of incidents - the challenges
The Risk Assessment process - as
easy as ABC
Our
request
Introduction
Within the myriad of incidents that occur in a healthcare
organisation a small, but significant, number result
in avoidable death or life long injury to either patients
or members of staff.
Creating
a framework to review such incidents, learn from them
and institute appropriate improvement strategies is
central to any risk management strategy. As well as
defining what constitutes a serious event in multi professional
teams, occupational health departments and staff side
committees there are also considerable learning outcomes
to be gained from assessing those incidents that:
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
download
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
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