Operational risk assessment.

In the world of risk management, which encompasses the business continuity disciplines, many types of risk require evaluation. Financial risk is most often the primary focus, followed by product and market risks. Another critical area, which typically lacks a thorough review or may be overlooked, is operational risk. This category encompasses many risk exposure types including those around building structures and systems, environmental issues, nature, neighbours, clients, regulatory compliance, network, data security and so on. At times, insurance carriers will assess internal hazards, but seldom do these assessments include more than a cursory look at other types of operational risk. In heavily regulated environments, risk assessments are required but may not always include thorough assessments of operational exposures. Vulnerabilities may linger or go unnoticed, only to become the catalyst for a business disruption at a later time, some of which are so severe that business recovery becomes nearly impossible. Businesses may suffer loss of clients as the result of a prolonged disruption of services. Comprehensive operational risk assessments can assist in identifying such vulnerabilities, exposures and threats so that the risk can be minimised or removed. This paper lays out how an assessment of this type can be successfully conducted.

Risk Stratification for Opioid Misuse in Children, Adolescents, and Young Adults: A Quality Improvement Project.

BACKGROUND: The Pediatric Palliative and Comfort Care Team (PACT) at Cincinnati Children's Hospital Medical Center (CCHMC) provides opioids to a large population of patients in the ambulatory setting. Before this project, PACT had no reliable system to risk stratify patients for opioid misuse. METHODS: The global aim was safe opioid prescribing by the palliative care team. The specific, measurable, achievable, realistic, and timely aim was as follows: "In patients who present for follow up with PACT, we will use the "opioid bundle" to increase risk stratification for opioid misuse from 0% to 90% over 5 months." The opioid bundle includes a urine drug screen, Ohio Automated Rx Reporting System report, pill count, and screening history for drug abuse and mental health disorders. The setting was multiple CCHMC ambulatory clinics. Participants included all PACT members. RESULTS: Since implementing the new system, we have increased risk stratification for opioid misuse among outpatients from 0% to >90%. Results have been sustained for 12 months. Key processes have become reliable: obtaining informed consent and controlled substance agreements for all new patients and obtaining the opioid bundle to enable risk stratification in a consistent and timely fashion. A total of 34% of patients have been stratified as high risk, and an additional 27% have been stratified as moderate risk. CONCLUSIONS: A system to ensure safe opioid prescribing practices to all patients is critical for providers. Identifying key processes and executing them reliably has enabled the palliative care team at CCHMC to risk stratify >90% of patients receiving opioids in the ambulatory setting for opioid misuse.

Feasibility and cost-effectiveness of a multidisciplinary home-telehealth intervention programme to reduce falls among elderly discharged from hospital: study protocol for a randomized controlled trial.

BACKGROUND: Fall incidents are the third cause of chronic disablement in elderly according to the World Health Organization (WHO). Recent meta-analyses shows that a multifactorial falls risk assessment and management programmes are effective in all older population studied. However, the application of these programmes may not be the same in all National health care setting and, consequently, needs to be evaluated by cost-effectiveness studies before to plan this intervention in regular care. In Italy structured collaboration between hospital staff and primary care is generally lacking and the role of Information and Communication Technologies (ICT) in a fall prevention programme at home has never been explored. METHODS AND DESIGN: This will be a two-group randomised controlled trial aiming to evaluate the effects of a home-based intervention programme delivered by a multidisciplinary health team. The home tele-management programme, previously adopted in our Institute for chronic patients, will be proposed to elderly people affected by chronic diseases at high risk of falling at hospital discharge. The programme will involve the hospital staff and will be managed thanks to the collaboration between hospital and primary care setting. Patients will be followed for 6 months after hospital discharge. A nurse-tutor telephone support and tele-exercise will characterize the intervention programme. People in the control group will receive usual care. The main outcome measure of the study will be the percentage of patients sustaining a fall during the 6-months follow-up period. An economic evaluation will be performed from a societal perspective and will involve calculating cost-effectiveness and cost utility ratios. DISCUSSION: To date, no adequately powered studies have investigated the effect of the Information and Communication Technologies (ICT) in a home fall prevention program. We aim the program will be feasible in terms of intensity and characteristics, but particularly in terms of patient and provider compliance. The results of the economic evaluation could provide information about the cost-effectiveness of the intervention and the effects on quality of life. In case of shown effectiveness and cost effectiveness, the program could be implemented into health services settings. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02487589 ).

Identification of patients with non-metastatic colorectal cancer in primary care: a case-control study.

BACKGROUND: Colorectal cancer is the third most common cancer worldwide and second most common in Europe. Despite screening, it is often diagnosed at an unfavourable stage. AIM: To identify and quantify features of non-metastatic colorectal cancer in primary care to enable earlier diagnosis by GPs. DESIGN AND SETTING: A case-control study was conducted using diagnostic codes from national and regional healthcare databases in Sweden. METHOD: A total of 542 patients diagnosed with non-metastatic colorectal cancer in 2011 and 2139 matched controls were selected from the Swedish Cancer Register (SCR) and a regional healthcare database respectively. All diagnostic codes (according to ICD-10) from primary care consultations registered the year before the date of cancer diagnosis (according to the SCR) were collected from the regional database. Odds ratios were calculated for variables independently associated with non-metastatic colorectal cancer using multivariable conditional logistic regressions. Positive predictive values (PPVs) of these variables were calculated, both individually and in combination with each other. RESULTS: Five features were associated with colorectal cancer before diagnosis: bleeding, including rectal bleeding, melaena, and gastrointestinal bleeding (PPV 3.9%, 95% confidence interval [CI] = 2.3 to 6.3); anaemia (PPV 1.4%, 95% CI = 1.1 to 1.8); change in bowel habit (PPV 1.1%, 95% CI = 0.9 to 1.5; abdominal pain (PPV 0.9%, 95% CI = 0.7 to 1.1); and weight loss (PPV 1.0%, 95% CI = 0.3 to 3.0); all P-value <0.05. The combination of bleeding and change in bowel habit had a PPV of 13.7% (95% CI = 2.1 to 54.4); for bleeding combined with abdominal pain this was 12.2% (95% CI = 1.8 to 51.2). A risk assessment tool for non-metastatic colorectal cancer was designed. CONCLUSION: Bleeding combined with either diarrhoea, constipation, change in bowel habit, or abdominal pain are the most powerful predictors of non-metastatic colorectal cancer and should result in prompt referral for colorectal investigation.

[Usefulness of natriuretic peptide testing and Doppler echocardiography at bedside in the diagnosis of acute heart failure]. / Apport du peptide natriurétique de type B et de l'échocardiographie Doppler transthoracique au lit du patient dans le diagnostic d'insuffisance cardiaque aiguë.

Acute heart failure is a common condition that leads to hospital admission, with important mortality and readmission rates. A prompt and accurate diagnosis of this condition by hospitalists is essential for an early and tailored medical management. The use of natriuretic peptide testing (BNP and NT-proBNP) through a two cut-point strategy is currently recommended as the first-line diagnostic complement to the initial clinical evaluation in the acute care setting. Transthoracic Doppler echocardiography is an other noninvasive method that can be used at bedside, especially in patients with intermediate, inconclusive natriuretic peptides levels. In this regard, left ventricular ejection fraction and several simple Doppler indexes (restrictive mitral filling pattern, spectral tissue Doppler E/e' ratio), have been validated in the emergency diagnosis of acute heart failure. The aim of the present review is to overview the respective contribution of natriuretic peptides and Doppler echocardiography at bedside to the diagnosis of acute heart failure in the acute care setting.

Supporting Threat Management with Forensic Expert Knowledge: Protecting Public Officials and Private Individuals.

This article describes the implementation of a Cantonal Threat Assessment and Management (CTAM) in Zurich, Switzerland. In order to support this endeavor, the Specialist Unit for Forensic Assessment and Case Management was installed. The forensic experts provide supervision and short-term assessments to public prosecutors and general psychiatrists. In close cooperation with police threat management units, forensic experts support the assessment and management of individuals who exhibit concerning and threatening behavior towards public officials or private individuals. A public official case study illustrates this joint approach. The author's experience with CTAM, its pitfalls and the potential areas of improvement are discussed. Copyright © 2016 John Wiley & Sons, Ltd.

Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Final rule.

This final rule establishes national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to plan adequately for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It will also assist providers and suppliers to adequately prepare to meet the needs of patients, residents, clients, and participants during disasters and emergency situations. Despite some variations, our regulations will provide consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters.

An Interprofessional Approach to Reducing the Risk of Falls Through Enhanced Collaborative Practice.

Falls are the leading cause of accidental deaths in older adults and are a growing public health concern. The American Geriatrics Society (AGS) and British Geriatrics Society (BGS) published guidelines for falls screening and risk reduction, yet few primary care providers report following any guidelines for falls prevention. This article describes a project that engaged an interprofessional teaching team to support interprofessional clinical teams to reduce fall risk in older adults by implementing the AGS/BGS guidelines. Twenty-five interprofessional clinical teams with representatives from medicine, nursing, pharmacy, and social work were recruited from ambulatory, long-term care, hospital, and home health settings for a structured intervention: a 4-hour training workshop plus coaching for implementation for 1 year. The workshop focused on evidence-based strategies to decrease the risk of falls, including screening for falls; assessing gait, balance, orthostatic blood pressure, and other medical conditions; exercise including tai chi; vitamin D supplementation; medication review and reduction; and environmental assessment. Quantitative and qualitative data were collected using chart reviews, coaching plans and field notes, and postintervention structured interviews of participants. Site visits and coaching field notes confirmed uptake of the strategies. Chart reviews showed significant improvement in adoption of all falls prevention strategies except vitamin D supplementation. Long-term care facilities were more likely to address environmental concerns and add tai chi classes, and ambulatory settings were more likely to initiate falls screening. The intervention demonstrated that interprofessional practice change to target falls prevention can be incorporated into primary care and long-term care settings.

A Model for Risk Assessment in Health Care.

The purpose of our research is to reduce risks and hence prevent errors in the health care process. The aim is to design an organizational information model using error prevention methods for risk assessment in a clinical setting. The model is based on selected indicators of quality nursing care, resulting from the world-known theoretical and practical models combined with experience in the Slovenian health care. The proposed organizational information model and software solution has a significant impact on the professional attention, communication and information, critical thinking, experience and knowledge.

Developing Methods of Repurposing Electronic Health Record Data for Identification of Older Adults at Risk of Unintentional Falls.

Nationally, nearly 40 percent of community-dwelling adults age 65 and older fall at least once a year, making unintentional falls the leading cause of both fatal and nonfatal injuries among this age group. Addressing this public health problem in primary care offers promise. However, challenges in incorporating fall risk screening into primary care result in a problem of missed opportunities for screening, counseling, intervention, and ultimately prevention. Given these barriers, this study examines the potential for the innovative use of routinely collected electronic health record data to provide enhanced clinical decision support in busy, often resource-thin primary care environments. Using de-identified data from a sample of West Virginia primary care centers, we find that it is both feasible and worthwhile to repurpose routinely collected data for the purpose of identification of older adults at risk of falls. Searching of both free-text and semistructured data was particularly valuable.

Inter-Rater Agreement of Pressure Ulcer Risk and Prevention Measures in the National Database of Nursing Quality Indicators(®) (NDNQI).

In this descriptive multi-site study, we examined inter-rater agreement on 11 National Database of Nursing Quality Indicators(®) (NDNQI(®) ) pressure ulcer (PrU) risk and prevention measures. One hundred twenty raters at 36 hospitals captured data from 1,637 patient records. At each hospital, agreement between the most experienced rater and each other team rater was calculated for each measure. In the ratings studied, 528 patients were rated as "at risk" for PrU and, therefore, were included in calculations of agreement for the prevention measures. Prevalence-adjusted kappa (PAK) was used to interpret inter-rater agreement because prevalence of single responses was high. The PAK values for eight measures indicated "substantial" to "near perfect" agreement between most experienced and other team raters: Skin assessment on admission (.977, 95% CI [.966-.989]), PrU risk assessment on admission (.978, 95% CI [.964-.993]), Time since last risk assessment (.790, 95% CI [.729-.852]), Risk assessment method (.997, 95% CI [.991-1.0]), Risk status (.877, 95% CI [.838-.917]), Any prevention (.856, 95% CI [.76-.943]), Skin assessment (.956, 95% CI [.904-1.0]), and Pressure-redistribution surface use (.839, 95% CI [.763-.916]). For three intervention measures, PAK values fell below the recommended value of ≥.610: Routine repositioning (.577, 95% CI [.494-.661]), Nutritional support (.500, 95% CI [.418-.581]), and Moisture management (.556, 95% CI [.469-.643]). Areas of disagreement were identified. Findings provide support for the reliability of 8 of the 11 measures. Further clarification of data collection procedures is needed to improve reliability for the less reliable measures. © 2016 Wiley Periodicals, Inc.

Pharmacovigilance in Europe: Place of the Pharmacovigilance Risk Assessment Committee (PRAC) in organisation and decisional processes.

The new European legislation that came into force in July 2012 reinforced the organisation of pharmacovigilance by setting up a committee in charge of risk assessment for medicines, the Pharmacovigilance Risk Assessment Committee (PRAC). The PRAC has a remit covering the assessment of all aspects of the safety and the risk management of medicinal products for human use in the European Union. It deals with issues regarding pharmacovigilance signals, the periodic evaluation of benefit/risk reports from marketing authorization holders (MAH), risk management plans, post-marketing studies, variations or renewals of marketing authorisations, management of under surveillance drugs lists, inspections for pharmacovigilance reasons and audits of pharmacovigilance systems. The PRAC works with the pharmacovigilance systems of the European Member States, which draw up evaluation reports. These evaluations are circulated and discussed by Member States so as to issue recommendations, which serve as a basis for other European medicines committees, the Committee for Medicinal Products for Human Use (CHMP) or the Coordination Group for Mutual Recognition and Decentralised Procedures-Human (CMDh) which then give their opinion. The final decision, which applies to all Member States and to the concerned MAH, lies with the European Commission (EC). This decisional procedure thus rests on coordination involving the PRAC, the CHMP, the CMDh, the EC, the Member States and the pharmaceutical companies. In the 3 years from July 2012, the PRAC has processed nearly 4500 procedures and is still facing an increasing workload.

Definition and use of Solution-focused Sustainability Assessment: A novel approach to generate, explore and decide on sustainable solutions for wicked problems.

This paper introduces Solution-focused Sustainability Assessment (SfSA), provides practical guidance formatted as a versatile process framework, and illustrates its utility for solving a wicked environmental management problem. Society faces complex and increasingly wicked environmental problems for which sustainable solutions are sought. Wicked problems are multi-faceted, and deriving of a management solution requires an approach that is participative, iterative, innovative, and transparent in its definition of sustainability and translation to sustainability metrics. We suggest to add the use of a solution-focused approach. The SfSA framework is collated from elements from risk assessment, risk governance, adaptive management and sustainability assessment frameworks, expanded with the 'solution-focused' paradigm as recently proposed in the context of risk assessment. The main innovation of this approach is the broad exploration of solutions upfront in assessment projects. The case study concerns the sustainable management of slightly contaminated sediments continuously formed in ditches in rural, agricultural areas. This problem is wicked, as disposal of contaminated sediment on adjacent land is potentially hazardous to humans, ecosystems and agricultural products. Non-removal would however reduce drainage capacity followed by increased risks of flooding, while contaminated sediment removal followed by offsite treatment implies high budget costs and soil subsidence. Application of the steps in the SfSA-framework served in solving this problem. Important elements were early exploration of a wide 'solution-space', stakeholder involvement from the onset of the assessment, clear agreements on the risk and sustainability metrics of the problem and on the interpretation and decision procedures, and adaptive management. Application of the key elements of the SfSA approach eventually resulted in adoption of a novel sediment management policy. The stakeholder participation and the intensive communication throughout the project resulted in broad support for both the scientific approaches and results, as well as for policy implementation.

Suicide Risk Documented During Veterans' Last Veterans Affairs Health Care Contacts Prior to Suicide.

A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow-up (n = 168; 57%). Fifty-three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide.

Documentary analysis of risk-assessment and safety-planning policies and tools in a mental health context.

Despite the articulated need for policies and processes to guide risk assessment and safety planning, limited guidance exists on the processes or procedures to be used to develop such policies, and there is no body of research that examines the quality or content of the risk-management policies developed. The aim of the present study was to analyse the policies of risk and safety management used to guide mental health nursing practice in Ireland. A documentary analysis was performed on 123 documents received from 22 of the 23 directors of nursing contacted. Findings from the analysis revealed a wide variation in how risk, risk assessment, and risk management were defined. Emphasis within the risk documentation submitted was on risk related to self and others, with minimal attention paid to other types of risks. In addition, there was limited evidence of recovery-focused approaches to positive risk taking that involved service users and their families within the risk-related documentation. Many of the risk-assessment tools had not been validated, and lacked consistency or guidance in relation to how they were to be used or applied. The tick-box approach and absence of space for commentary within documentation have the potential to impact severely on the quality of information collected and documented, and subsequent clinical decision-making. Managers, and those tasked with ensuring safety and quality, need to ensure that policies and processes are, where possible, informed by best evidence and are in line with national mental health policy on recovery.

Postpartum Hemorrhage Preparedness Elements Vary Among Hospitals in New Jersey and Georgia.

OBJECTIVE: To identify the presence or absence of 38 postpartum hemorrhage preparedness elements in hospitals in New Jersey and Georgia as a component of the Postpartum Hemorrhage Project of the Association of Women's Health, Obstetric and Neonatal Nurses. DESIGN: Quality improvement baseline assessment survey. SETTING: Hospitals (N = 95) in New Jersey and Georgia. PARTICIPANTS: Key informants were clinicians who were members of their hospitals' obstetric teams and were recognized as knowledgeable about their hospitals' postpartum hemorrhage policies. METHODS: An electronic survey was sent by e-mail to each identified hospital's key informant. RESULTS: The mean number of elements present was 23.1 (SD = 5.2; range = 12-34). Volume of births, students, magnet status, and other hospital characteristics did not predict preparedness. None of the hospitals had all of the 38 preparedness elements available. Less than 50% of the hospitals had massive hemorrhage protocols, performed risk assessments and drills, or measured blood loss. For every 10% increase in the total percentage of African American women who gave birth, there was a decrease of one preparedness element. CONCLUSION: Objective measures of preparedness are needed, because perceptions of preparedness were inconsistent with the number of preparedness elements reported.

Limitations to the Use of Species-Distribution Models for Environmental-Impact Assessments in the Amazon.

Species-distribution models (SDM) are tools with potential to inform environmental-impact studies (EIA). However, they are not always appropriate and may result in improper and expensive mitigation and compensation if their limitations are not understood by decision makers. Here, we examine the use of SDM for frogs that were used in impact assessment using data obtained from the EIA of a hydroelectric project located in the Amazon Basin in Brazil. The results show that lack of knowledge of species distributions limits the appropriate use of SDM in the Amazon region for most target species. Because most of these targets are newly described and their distributions poorly known, data about their distributions are insufficient to be effectively used in SDM. Surveys that are mandatory for the EIA are often conducted only near the area under assessment, and so models must extrapolate well beyond the sampled area to inform decisions made at much larger spatial scales, such as defining areas to be used to offset the negative effects of the projects. Using distributions of better-known species in simulations, we show that geographical-extrapolations based on limited information of species ranges often lead to spurious results. We conclude that the use of SDM as evidence to support project-licensing decisions in the Amazon requires much greater area sampling for impact studies, or, alternatively, integrated and comparative survey strategies, to improve biodiversity sampling. When more detailed distribution information is unavailable, SDM will produce results that generate uncertain and untestable decisions regarding impact assessment. In many cases, SDM is unlikely to be better than the use of expert opinion.

Degrees of connectivity: Systems model for upstream risk assessment and mitigation.

There is growing recognition that in order to further improve safety performance, attention needs to be given beyond the immediate working conditions and worker actions. A systems approach to construction safety enables considering: multiple project elements simultaneously; connections between different elements; and all system elements affected by safety risk. This paper describes recent and current research to conceptualize a typical building project in terms of connections between workers, activities, and design elements, and to verify and analyze impacts of the design and worker interactions on worker safety. Prior research provides the basis for a network tying the design elements, construction activities, and work crews on a typical building project together along with the extent of interaction between each of the system elements in terms of safety. In conjunction with this systems approach, the researchers propose a concept for viewing and managing construction safety through four different types of connections, or "degrees of connectivity," between the different workers, activities, and design elements in the system. The degrees of connectivity are defined as: interacting with the design element during its construction (DoC #1); interacting with the design element in its final form to attach another component to it (DoC #2) or by working in the vicinity of it (DoC #3); and indirectly interacting with the design element through another worker (DoC #4). To support and verify the presence of the concept in practice, the researchers conducted a survey of construction personnel. The survey results confirm that the four different degrees of connectivity are present and felt during construction operations, and indicate that attention should be given to all design elements, activities, and workers to which a worker is "connected". According to the survey respondents, DoC's #1 and #2 are recognized as the most widely present on construction sites. Eighty percent of the respondents believe that the design element has a moderate or greater impact on worker safety while it is being constructed. These initial research steps provide the starting point for continuing study that aims to develop and demonstrate the degrees of connectivity concept linking workers and design elements, with the goal of understanding how to design a project and work operations in order to improve safety during construction.