HIROC Risk Reference Sheets Refresh – Check them out today!
What are HIROC's Risk Reference Sheets?
Did you know, every one minute and 18 seconds a preventable patient safety incident occurs in Canada? It is projected that over the next thirty-years a death from a preventable incident may occur every thirteen minutes (CPSI, 2017).
HIROC’s Risk Reference Sheets are one-page summaries of safety and risk learnings that are informed from evidence, HIROC claims experiences, and reviewed by experts. As a trusted healthcare safety advisor, HIROC insures and is a partner in safety in over 700 healthcare organizations across Canada. Our claims database provides a wealth of safety learnings at the system, team, practitioner and patient level.
Risk Reference Sheets aim to start committed conversations on safety and support decision-making. The following graphic illustrates how HIROC identifies risks from Subscribers’ claims experiences, rank these risks, create Risk Reference Sheets and Risk Assessment Checklists to start committed conversations on safety, and support integrated risk management decision making.
The Importance of Continuous Learning
Following best practices for evidence-informed tools - the risk ranking of claims and the review of Risk Reference Sheets takes place every three years to ensure accurate and relevant information.
In 2020, the Risk Reference Sheets reviewed included a focus on themes with a high degree of preventability, high severity from a loss or harm perspective as well as the most likely contributing factors associated with losses and safety incidents resulting in medical-legal claims.
New Risk References Sheets for 2020
New additions to the top 30 ranked risk list for acute care organization in 2020 include:
- Failure to identify/manage neonatal hypoglycemia
- Delayed decision to delivery time for Caesarian Section
- Mismanagement of neonatal resuscitation
- Vaginal birth after a prior Caesarian section
- Failure to identify/management postpartum hemorrhages and hemorrhagic shock
- Cyber loss
- Windstorms
Several of the Risk Reference Sheets and accompanying Risk Assessment Checklist modules continue to reflect patient safety themes, recognized as never events, that are patient safety incidents resulting in serious patient harm or death that are preventable.
Furthermore, two new Paramedic/Emergency Medical Services Risk Reference Sheets and Risk Assessment Checklist modules were released in October 2020 that focused on:
- Ineffective communications in the pre-hospital setting
- Airway mismanagement
The value of Risk Reference Sheets
Risk Reference Sheets aim to start committed conversations on safety and support decision-making and may add value by being a:
- Source of risk and safety information to accompany other internal and external documents used as part of an organization's integrated risk management program
- Safety resource and onboarding tool for new program directors and managers
- Reference source during critical incident investigation
- An education tool for program in-services and rounds
We’re here to support you and your team on your safety journey
Is your organization participating in the Risk Assessment Checklists Program? If not, our team would be delighted to share more information.
Looking to learn more about how HIROC’s tools and resources can guide decision making at your organization? We would love to connect -- please forward any questions and inquiries to riskmanagement@hiroc.com.