Risk Management Event Evaluation and Responsibilities

Link to article at PubMed

2020 Dec 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–.


Risk management in healthcare is a complex set of clinical and administrative systems, processes, procedures, and reporting structures designed to detect, monitor, assess, mitigate, and prevent risks to patients. Currently, the numerous risk management practices and processes that occur in healthcare organizations are a response to The Institute of Medicine’s (“IOM”) report entitled “To Err is Human: Building a Safer Health System.”

In the report, the IOM noted that approximately 98,000 people die in any given year from medical errors while in the hospital. As a result of the report, Congress enacted the Patient Safety and Quality Improvement Act (“PSQIA”) of 2005 (hereafter referred to as “The Act”).

Legal commentators reviewed the impact of The Act and articulated several of its key principles and responsibilities. These duties include:

  1. Provision for the certification and recertification of Patient Safety Organizations (“PSO’s”)

  2. Collection and dissemination of information related to patient safety

  3. Establishment of a patient safety database

  4. Facilitation of the development of consensus among healthcare providers, patients, and other interested parties concerning patient safety and recommendations to improve patient safety

  5. Provision of technical assistance to states that have (or are developing) medical-error reporting systems

  6. Provision of assistance to the states in developing standardized methods for data collection, and collection of data from state reporting systems for inclusion in the patient safety database.

The fundamental goal of this act was to increase the nation’s overall patient safety by encouraging confidential and voluntary reporting of adverse events that affected patients. Policymakers theorized that the systematic collection of medical-error data could achieve improved patient safety and that the awareness of such error-data by health care providers and administrators would lead to the prevention of errors and the global reduction of their recurrence.


Sentinel Event: Defined by the Joint Commission as “a patient safety event that results in death, permanent harm, or severe, temporary harm” (The Joint Commission 2017). These events are typically unrelated to the patient’s illness/underlying condition. It is important to note that the Joint Commission requires each accredited organization to establish its own definition for a sentinel event to prevent, review, and respond to these occurrences.

Medical Error: The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. In the context of this article, medical errors may fall under the definition of sentinel events if the error is severe enough.

Root Cause Analysis: The process for identifying the basic or causal factor(s) underlying variation in performance. Also established by the Joint Commission, this multi-step process is crucial to identify and fix systemic problems in patient safety and care.

Risk Management: Clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself (The Joint Commission 2017).

PMID:32644752 | Bookshelf:NBK559326

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