Why focus on risk?

Published on 24/05/2015 by admin

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Last modified 24/05/2015

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Chapter 1 Why focus on risk?

Clinical risk assessment should be motivated primarily by the intention to provide a patient with better treatment and care.¹

This book is designed to assist clinical practice by providing the knowledge and skills to apply sound risk management techniques in day-to-day work. The purpose of applying these risk management techniques is to provide better outcomes for patients, staff and the community. The risk management processes contained in this book aim to ensure that all reasonable steps to promote wellbeing and provide adequate safeguards against avoidable harm have been taken during a patient’s treatment and care. Understanding and pursuing the assessment (and management) of risk to oneself and others is part of the required standard of ordinary clinical practice.² This book is primarily a clinical guide, but can also be used as a teaching tool.

Principles of risk management

Within mental health settings, risk management used to be considered the business of predicting and preventing dangerousness.

The traditional focus of risk-taking, in mental disorder services, involved concentrating on a patient’s dangerousness. With this approach, there was an implicit assumption that ‘risk’ was limited to failures, to the causing of harm.³

The focus of risk management today is not so much on the end point of preventing the adverse outcome, but more on enhancing clinicians’ performance at all stages of treatment to achieve a good outcome for the patient. This is attained through focus on:

• skills acquisition and decision-making

• management of risk factors in the context of illness and with recovery principles in mind

• organisational factors.

Much medical effort goes into managing the risks of complications of disease processes rather than managing the symptoms of the disease itself. Hypertension is the classic example, with no symptoms but plenty of treatments, all aiming to reduce the risk of complications such as strokes and myocardial infarctions. Psychiatry’s misfortune has been to choose diseases where the complications … are homicide, suicide or reduced capacity for self-care and vulnerability.⁴

This problem becomes the nub of risk management within mental health. On the one hand clinicians try to treat the illness while at the same time managing the risk, which is often a complication of the disease process rather than a symptom of the disease itself. ‘Risk, especially violence, can be a preventable complication of some types of mental disorder.’⁵

This book focuses primarily on skills acquisition and the process of decision-making. It provides opportunities to practise some of the suggested techniques in the case examples. Organisational factors are touched on briefly but are predominantly the brief of senior clinicians, team leaders and clinical leaders. Detailed discussion of organisational factors is beyond the scope of this book but an introduction is given in Part 4.

Guidelines vary from country to country and are dependent mostly on the structure of health services rather than clinical differences. Good risk management involves having knowledge of guidelines and knowing how to access them. Guidelines should be available in printed form at your workplace. Some guidelines currently available, and useful in conjunction with this book, include:

Suicide

• New Zealand Suicide Guidelines 2003. Available from www.nzgg.org.nz

• Click on ‘Publications’ and then ‘Mental Health’.

Risk to others

• Guidelines for the Assessment and Management of Risk to Others, 2006. Available from www.tepou.co.nz/page/tepou_23.php

• Click on ‘Publications’.

• Violence: The short-term management of disturbed/violent behaviour in inpatient psychiatric settings and Emergency Departments (EDs). Available from National Institute of Clinical Excellence: http://www.nice.org.uk/Guidance/CG/Published

Self-harm

• Australasian Self-harm Guidelines. Summary in Australasian Psychiatry, 2003 (11)2: 150–5.

• Guidelines for the Management of Deliberate Self-harm in Young People. Available from Australasian College of Emergency Medicine and Royal Australian and New Zealand College of Psychiatrists.

• Self-harm: The Short-Term Physical and Psychological Management and Secondary Prevention of Self-harm in Primary and Secondary Care. Available from National Institute of Clinical Excellence: http://www.nice.org.uk/Guidance/CG/Published

This book is only one step in learning about risk assessment and management. Further steps include:

• Implementing the clinical skills learned and gaining familiarity with the process of risk assessment and management. Being unfamiliar with a task can increase the likelihood of error by a factor of 17.⁶

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