Procedure Non-Attendance Booked patients who fail to arrive Procedure Cancellations Cancellation after arrival due to pre-existing medical condition Cancellation after arrival due to an acute medical condition Cancellation after arrival due to admin / organisational reasons Unplanned Return to the Operating Theatre Unplanned return to the operating room on same day as initial procedure Unplanned Transfer / Admission Unplanned transfer or overnight admission related to procedure Unplanned transfer or overnight admission related to ongoing mgmt. Discharge Unplanned delayed discharge for clinical reasons >1hr beyond expected Unplanned delayed discharge non-clinical reasons >1hr beyond expected Medication Errors Medication errors – adverse event requiring intervention Central Line-Associated Blood Stream Infections Haematology Unit-related CI-CLABSI Haematology Unit-related PI-CLABSI Oncology Unit-related CI-CLABSI Oncology Unit-related PI-CLABSI OPIV Unit-related CI-CLABSI OPIV Unit-related PI-CLABSI Haemodialysis-Associated Bloodstream Infection Surveillance Haemodialysis – AV-fistula access-associated BSI Haemodialysis – synthetic access-associated BSI Haemodialysis – native vessel graft access-associated BSI Haemodialysis – CI non-cuffed line access-associated BSI Haemodialysis – CI cuffed line access-associated BSI Healthcare Associated MRSA Morbidity Non ICU associated new MRSA inpatient HAIs in a sterile site Non ICU associated new MRSA inpatient HAIs in a non-sterile site Occupational Exposures to Blood and/or Body Fluids Reported parenteral exposures sustained by staff Reported non-parenteral exposures sustained by staff Pre-Anaesthesia Period Pre-anaesthesia consultation completed by anaesthetist Patient Recovery Period Unplanned stay in recovery room >2 hrs for medical reasons Cataract Surgery Cataract surgery readmission within 28 days Cataract surgery readmission within 28 days due to endophthalmitis Cataract surgery unplanned overnight admission Cataract surgery – anterior vitrectomy Failure to Caecum Failure to reach caecum due to inadequate bowel preparation Failure to reach caecum due to diseased colon Failure to reach caecum due to instrument failure
Risk Details Form Primary and Secondary Risk Types – Examples Primary Risk Category Secondary Risk Category Additional description if required Potential consequences / contributing factors Existing controls Business Continuity Disruption to essential services Disruption to essential services includes those services which would impact on the continuity of operations, management of the security and operability of communications systems. Disruption to essential services may result from power outages including emergencies power outage and interruption to water and waste management supply. Harm to clients. Disruption to clinical services. Loss of clinical information. Breach of regulatory waste management requirements. Natural disaster. Inadequate back-up systems, or failure of back-up systems to provide adequate Non-compliance with procedure for managing back-up systems. Procedures to be followed in the hours preceding a storm to protect computers, paper records etc. are specified (Documents Register) Recovery processes, including procedures for impact assessment, repair/restoration, alternate solutions, post-incident analysis, and the updating of the emergency management plan are specified (Documents Register) Communication response team, defining employee roles and responsibilities and establishing a chain of command for operational functions and maintenance of communications infrastructure and IT services, are specified (Documents Register) Staff Mandatory training, includes training for all phases of an emergency are scheduled (Training Register). Communications leader training for those responsible for coordinating communications operations during major emergency events, is scheduled (Training Register). Employee contact lists maintained with details of employee’s office, mobile and personal numbers, office and personal email addresses. Requirements for databases to be backed up at the last possible moment, are specified. Emergency plan documented and available to all staff (Documents Register). Service provider contact detailing contact information for IT, Internet, and
telecommunications services, documented (LOGIQC Business Contacts). Back-up power generator installed with procedures for regular testing and maintenance is scheduled (Compliance Register). Procedures for the management of waste are in place (Compliance Register). Collaborative partnerships Breakdown in relationship with Suppliers include those who provide goods or services to our organisation, including those who provide services to our clients; and other groups without whose support the organisation would cease to exist. Continuity of care to clients compromised. Capacity of health service to provide support to clients to access complementary services compromised. Loss of reputation and credibility. Supplier relationships do not down overnight. Often the reasons or causes for the breakdowns are not those in the moment, but those that companies do not adequately prepare for. A breakdown with the supplier relationship is often tied to a mistake that takes place days, months or even years before. mistakes take many forms, but usually fall into one of four categories: (1) pre-contract mistakes, (e.g. inadequate request for quotation, failing to conduct adequate diligence on any potential supplier); (2) contracting mistakes, (e.g. failure to be precise regarding what the final contract is comprised of); (3) relationship mistakes, (e.g. failure to monitor performance and resolve problems as they arise); (4) termination mistakes (e.g. failing to terminate contract effectively). Criteria for measuring supplier performance determined at the outset and included in suppliers’ contracts. Performance relating to an Approved Supplier is reviewed annually and managed (Suppliers Register). Issues with a supplier’s performance are addressed through routine procedures. Suppliers’ contracts include clauses for resolving conflicts and an Exit Agreement clause is included to ensure intellectual property is returned, and where applicable, continuity of care to clients is preserved with minimum interruption to service delivery. All staff are required to report non-conformances relating to approved suppliers (Improvement Register). If the external supplier is an approved supplier the issue will be reported as a “related item” to the respective supplier on the Approved Suppliers Register in LOGIQC. Otherwise issues are recorded as “non-conformances” directly onto the Improvement Register in LOGIQC.
effectively manage requires organisation wide medication safety systems. Higher insurance premiums and policy conditions or deductibles. Breach of regulatory / standards / contractual requirements. Litigation / legal action. Lost time resulting from the management of litigation resulting in loss of productivity. Inadequate procedures. Storage of medications not logically categorised making it hard for nursing staff to recognise medications. / contracted service providers not following clinical policies and procedures. Inadequate monitoring of other service provider performance. Inadequate oversight by management. All staff required to report non-conformances and near misses (Improvement Register). Infection control procedures included in staff induction program. A range of internal audits are conducted to ensure compliance with medication safety requirements are scheduled (Audits Register). analysis of non-conformances relating to medication safety undertaken by management (LOGIQC Reports tab). The organisation participates in external certification and accreditation processes, which identifies required policies and procedures to support safe practices (Audits Register). with clinical procedures / standards Relates to staff not following the organisation’s clinical policies and procedures and recognised health care standards. Harm to clients. Loss of reputation and credibility. Higher insurance premiums and policy conditions or deductibles. Breach of regulatory / standards / contractual requirements. Litigation / legal action. Lost time resulting from the management of litigation resulting in loss of productivity. Unqualified Inadequate staff induction. Inadequate supervision or training. Inadequate procedures. Staff / contracted service providers not following clinical policies and procedures. Inadequate monitoring of other service provider performance. Inadequate oversight by management. Procedures for managing clinical processes are specified and available to all (Documents Register). Induction program for new staff includes clinical procedures. Internal and external audits of clinical practices are scheduled (Audits Register). Contracts with external service providers are managed (Contracts Register). Mandatory and good practice clinical requirements are scheduled (Compliance Register). Clinicians who are external service providers are Approved Suppliers and performance is periodically reviewed (Suppliers Register).
Over-reliance on a small number of The organisation is reliant on a supplier whose failure to supply could impact on the organisation’s capacity to provide services. Organisation’s capacity to deliver services could be affected. Organisation’s capacity to generate income could be affected. Cash flow be affected. The business is highly dependent on a small number of suppliers. One supplier of the business provides 30% or more of the product requirements. Contracts are in place to lock-in major suppliers through long-term service contracts (Contracts Register). In critical areas arrangements are in place for more than one supplier who is capable of supplying similar items to the organisation (Suppliers Register). Human Cross cultural conflict Conflict between different cultural practices and beliefs. Loss of reputation and credibility. Loss of clients. Loss of Litigation / legal action. Organisational values not clearly defined. Inadequate staff induction training. Inadequate cultural sensitivity training for Inadequate management oversight. Our model of working with clients and staff is underpinned by a commitment of empowerment. Staff mandatory training includes cross cultural awareness and cultural sensitivity (Suppliers Register). Staff Grievance procedure is specified (Documents Register) Conflict resolution procedure is specified (Documents Register) Mediation processes that provides both parties with opportunities to put forward their views and assist in analysing the problem and looking for solutions is specified (Documents Register). Industrial action According to the Fair Work Act industrial action can take several forms. Employees may go on strike (i.e. refuse to attend or perform work) or impose work bans (i.e. refuse to perform all their normal duties). In response to employee Industrial action. Litigation / legal action. Loss of Lost time resulting from the management of litigation resulting in loss of productivity. Breach of Industrial Awards and conditions. Unfair work practices. Breach of the Enterprise Agreement. Negotiating an Enterprise Agreement. A key objective of the Fair Work Act 2009 is achieving productivity and fairness in the workplace through the implementation of collective bargaining underpinned by simple good faith bargaining obligations and clear rules governing industrial action.
industrial action, employers may lock out their employees (i.e. close the doors or gates of a workplace and refuse to allow them to work). Lack/insufficient skills, training to complete job duties Relates to employee competencies, which include traits, skills or attributes that employees need to perform their jobs most effectively, which will vary by job and position. Harm to clients. Breach of regulatory / contractual / standards requirements. Higher insurance premiums and policy conditions or deductibles. Litigation / legal action. Loss of reputation and credibility. Lost time resulting from the management of litigation resulting in loss of productivity. Position statements not reflecting require qualifications, skills and experience. Staff not being appointed on merit. Inadequate staff induction. Inadequate supervision or training. Inadequate performance planning and review processes with staff. Inadequate oversight by management. Position statements outline staff qualifications and professional registration requirements. Staff performance reviews are conducted to ensure staff have the skills and competencies to undertake their duties (Compliance Register). Mandatory training for each member of staff is scheduled (Suppliers Register). Staff licences and registration checks are scheduled (Licensing Register). with HR procedures Relates to staff not following the organisation’s HR policies and procedures, awards and conditions of employment, and applicable legislative requirements. Breach of regulatory / contractual / standards requirements. Higher insurance premiums and policy conditions or deductibles. Litigation / legal action. Loss of reputation and credibility. Inadequate staff induction. Inadequate staff supervision or training. Inadequate procedures. Inadequate systems for managing HR processes. Staff not following clinical policies and procedures. Inadequate oversight by management. Procedures for managing HR processes are specified and available to all staff (Documents Register). Upon appointment of new induction requirements are scheduled (Compliance Register). Internal audits of HR practices are scheduled (Audits Register).
Top management has oversight responsibility of the Compliance Register. Management Assets mismanagement ISO 55000 defines Asset management as the "coordinated activity of an organization to realize value from assets". In turn, Assets are defined as follows: "An asset is an item, thing or entity that has potential or actual value to an organization" which is wider than physical assets. Loss of capital value. Breach of warranty agreements. Inadequate procedures for the management of assets. Inadequate systems for tracking and tracing organisational assets. Inadequate systems for the protection of organisational assets. Inadequate oversight by management. An Assets Register is maintained, which lists all assets over the value of insert value Warranty agreements are managed and periodically reviewed (Contracts Register). Preventive maintenance / calibration / validation requirements outlined in Warranty Agreements are scheduled (Compliance Register). Staff training in the use of specialised equipment is scheduled (Suppliers Register). Annual review of the inventory of equipment listed on the Assets Register is scheduled (Audits Register). All staff required to report damage / loss / breakdown / misuse of equipment (LOGIQC Repairs/Improvement/Incidents Register). Client transport mismanagement Transport service provided to clients to assist with access to the organisation’s health service and/or to external health services. Compromised client safety. Harm / injury to clients. Breach of vehicle agreement / insurance policy / road rules. Loss of capital asset value. Loss of / reputation. Unqualified staff. Inadequate procedures. Inadequate induction. Staff not following transport policies and procedures. Inadequate staff supervision or training. Organisation culture does not hold management and staff accountable for safe work practices. Inadequate management oversight of client transport service. Inadequate vehicle insurance. Procedures for managing client transport service are specified and periodically reviewed (Documents Register). Dedicate staffing resources to provide client transport service have been allocated. Induction program for new staff includes procedures relating to client transport. Appointment system to manage client transport requests is in Vehicle safety checks are scheduled (Audits Register). Performance of the client transport service is scheduled to review cost efficiencies and client
satisfaction with services provided (Audits Register). Driver authority and driver licences are checked upon appointment and periodically re-checked (Licensing Register). Annual check of currency of driver’s licences are scheduled (Licensing Register). Requirement of staff to report changes in Driver’s Licence status are specified. All staff required to report damage / loss relating to the organisation’s vehicle fleet (LOGIQC Repairs/Incidents/Improvement Register). Preventive maintenance schedule, as per Vehicle Lease Agreements are schedule (Compliance Register). Driver Safety Training scheduled for designated is scheduled (Suppliers Register). Lease agreements, vehicle registrations and vehicle insurance are managed (Contracts Register). Equipment mismanagement Proper management of the equipment in health care services is necessary to ensure accurate, reliable, and timely diagnosis. Incorrect or missed diagnosis. Variation in diagnosis. Loss of confidence in the accuracy of testing results. Increased repair costs. Shorten life of equipment. Delayed or interruption of services due to breakdowns and failures. Inadequate staff induction. Inadequate systems for ensuring equipment is calibrated / validated and certified. Inadequate staff supervision or training in the use of equipment. Inadequate procedures. Inadequate oversight by management. An Assets Register is maintained, which lists all equipment over the value of insert value Warranty agreements are managed (Contracts Register). Preventive maintenance / calibration / validation requirements outlined in Warranty Agreements are scheduled (Compliance Register). Where applicable, the induction program for new staff includes procedures in the safe use of equipment.
Decrease in client satisfaction with health care. Harm to clients and visitors. Unsafe work environment for staff. Loss of image / reputation. Loss of capital value of equipment assets. An inventory of equipment listed on the Assets Register is scheduled (Audits Register). All staff required to report damage / loss / breakdown / misuse of equipment (LOGIQC Reports tab). Staff training in the use of specialised equipment is scheduled (Suppliers Register). Hazard mismanagement are six types of hazards: Biological – e.g. bacterial, virus, insects Chemical - e.g. toxicity Ergonomic - e.g. repetitive, inappropriate use Physical - e.g. radiation, magnetic Psychological - e.g. stress, violence Safety - e.g. inappropriate guarding, equip malfunction Harm to clients and visitors. Unsafe work environment for staff. Breach of WHS Act. Litigation / action. Loss of reputation and credibility. Lost time resulting from the management of litigation resulting in loss of productivity. Inadequate procedures. Inadequate staff induction. Inadequate staff reporting requirements. Organisational culture does not hold management and staff accountable for safe work environment. Inadequate management oversight of WHS. Procedures for managing hazards are specified and available to all (Documents Register). Induction program for new includes procedures for reporting and managing hazards. Hazard identification is part of the Environmental Safety Audit (Audits Register). Designated positon with responsibility for coordinating the WHS Program has been determined. WHS Committee established with oversight of the workplace health and safety, including hazard management. All staff are required to report non-conformances in relation to these requirements (Improvement Register). Information management Information management (IM) concerns a cycle of organisational activity: the acquisition of Agencies and organisations have obligations under the Privacy Act 1988 (Cth) to put in place reasonable security safeguards and to Data breaches are not limited to malicious actions, such as theft or ‘hacking’, but may arise from internal errors or failure to follow information Data breach policy and response plan that includes notifying affected individuals are specified and available to all staff (Documents Register).
Vehicle mismanagement Vehicle management includes procedures relating to vehicle purchase / leasing, maintenance, accident and fuel management, vehicle fit-out and disposal with the aim of reducing costs in the purchase and maintenance of vehicles and increasing vehicle safety. Reduction in the value of the asset. Higher insurance premiums and policy conditions or deductibles. Cost inefficiencies. Inappropriate use. Breach of Salary Sacrifice regulations. Inadequate procurement procedures. Inadequate procedures for the management and storage of vehicles. Inadequate insurance. not following vehicle management policies and procedures. Inadequate oversight by management. Procedures for procurement, use of vehicles, managing accidents, and refuelling are specified and available to all staff (Documents Register). Comprehensive insurance for vehicles are in and managed (Contracts Register). Vehicle registrations are managed (Compliance Register). Preventive maintenance as per the / Warranty Agreement is scheduled (Compliance Register). Delegations of authority for managing vehicles is specified. All staff are required to report non-conformances in relation to these requirements (Improvement Register). Operations & Assets with operational procedures Relates to staff not following the organisation’s operational policies and procedures, recognised standards and applicable legislative requirements. Breach of regulatory / contractual / standards requirements. Litigation / legal action. Loss of reputation and credibility. Lost time resulting from the management of litigation resulting in loss of productivity. Unqualified Inadequate induction. Inadequate staff supervision or training. Inadequate procedures. Staff not following operational policies and procedures. Inadequate oversight by management. Procedures for managing operational processes are specified and available to all staff (Documents Register). Induction program for new includes operational procedures relevant to staff’s work area. Internal audits of critical operational processes are scheduled (Audits Register). Contracts with critical suppliers are managed (Contracts Register). Critical Suppliers who we rely on to support our operations are approved suppliers and periodically reviewed (Suppliers Register).
Financial incident - Inaccurate accounting and/or reporting Hazard - Safety - inappropriate guarding, equip malfunction HR Incident - Litigation claim HR Incident - Non-conformance with HR requirements Legal Incident - Legal penalties Medication Incident - Incorrect drug Security incident - Copyright violation Compliance / Human Resource/Personnel Non-conformance with HR procedures HR incident - Staff absenteeism HR incident - Non-conformance with HR requirements Issue with access to services Issue with staff courtesy Compliance / Client Safety Non-conformance with clinical procedures / standards Clinical Practice - Medical Negligence Clinical Practice - Clinical standards not followed Issue with clinical care with clinical information provided Compliance / legal Management Information mismanagement ICT incident - Unauthorised file deletion ICT incident - Loss of IT data Security incident – Unauthorised access of patient information Security incident – Unauthorised release of patient information Security incident – Unauthorised access to information Security incident – Unauthorised release of information Security incident - Privacy breach Security incident - Security breach Equipment Management Assets mismanagement Equipment incident - Damage Equipment incident - Failure Equipment incident - Loss Equipment incident - Misuse Equipment incident - Use of uncertified equipment
Technology Technological Not maximising the potential benefits of digital technologies Equipment Incident – failure Inventory Incident - Expired medical product Inventory Incident - Inadequate stock Technology Technological Breach of data security and backup Security incident - Unauthorised access to information Security incident - Unauthorised release of information Security incident - Unauthorised access to patient information Security incident - Unauthorised release of patient information Security incident - Security breach ICT incident - Backup systems failure ICT incident - Loss of IT data ICT incident - Inappropriate Use of Technology / Internet ICT incident - Unauthorised File Deletion ICT incident - Intrusion / Virus Technology Technological Loss of productivity due to staff IT competencies HR Incident - Inadequate training