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Risk management


somebody home you may miss the opportunity to identify and respond to an emerging complication not present at time of discharge, whereas in a 


 standpoint, but there is also a secondary factor, which is that when they are in the hospital you try to discharge them at exactly the right time so that they don’t boomerang back to you in 24 hours—which would 


Timing is also of the essence when problems do occur. “The biggest


 


“We have members who will call us from the operating theatre to tell us about something that just happened—in which case, we advise them    the scale, we’ll have members who call a month or two after the event.


“The golden moments of risk management are within the hours of the event unfolding—like the golden 24 hours of search and rescue.           writing notes on the record, and you’re interacting with the patient or their family members. The biggest challenge is getting our members to 


                such as NASA.


   and highly trained people and they all have to interact with each other   


Dissecting an event  doing that, especially the quality of the analytics that they use in the root cause analysis, and the skillset that goes into being able to carry one out.


“There is no national standard, for example, that says someone is  do try diligently to work these things out, but at the end of that process you have lukewarm corrective action plans because the skillset going into 


The key to improving the situation, he says, is training backed by information. 


“Aircrafts have black boxes so that you are able to reconstruct what happened to understand what went wrong. We don’t have black boxes in healthcare, and until it is possible to look back at a complex situation and have a uniform method of getting that ‘black box’ type information, we  


20 | HEALTHCARE RISK MANAGEMENT REVIEW | Annual 2014


“The golden moments of risk management are within the hours of the event unfolding—like the golden 24 hours of search and rescue.”


                                          


“They show how to do a causation analysis from an engineering


  analysis and your analytics actually show.


“These sessions have been very well attended for two years and some hospitals


  the trade, and everyone walked out of that eight-hour workshop able to go back to their institutions and put what they had learned into practice.


 


 


McMullin believes that in order to be equipped for the future, this is


what healthcare risk managers need more of: practical steps that they can put into action when problems arise. With this in mind, the next          those needs with an equally practical focus.


 their day-to-day activities they are so busy running around and taking care of all the things in their facility that what they are really looking for are tools they can put in their tool belt and take out and put to work on that problem 


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