Risk Management is a collective effort of all MEDDAC staff to minimize harm to patients, staff and visitors and reduce liability.  This is accomplished through a coordinated program of monitoring and actions to reduce potential and actual harm and liability by:

• Providing an early warning system of data analysis that identifies problem areas before Potentially Compensable Events (PCEs) occur

• Minimizing potential liability once an adverse event occurs

• Encouraging sensitive/responsive interactions between staff, patients and visitors.

• Directs, coordinates and evaluates the program

• Collaborates with appropriate staff including Patient Safety regarding risk issues

• Coordinates the standard of care/peer review process ensuring that it is done appropriately

• Manages claims against the government (database & tracking processes)

• Consults with the Judge Advocate General (JAG) Administrative Law and Claims attorneys on patient risk issues

• Reports all Sentinel Events to The Joint Commission (TJC) and collaborates in the Root Cause Analysis and develop of the plan to reduce the risk of future harm to patients

RM Definitions:

Potentially Compensable Event (PCE):  An adverse event that occurs in the delivery of healthcare and services with resulting beneficiary harm.  It includes any adverse event or outcome, with our without legal fault, in which the patient experiences any unintended or unexpected negative result.

Significantly Involved Providers: Individuals who actively delivered care in either primary or consultative roles during the episode of care that gave rise to the allegation of malpractice.  This applies to all disciplines not just privileged providers.

Sentinel Events: Unexpected incident involving death or major permanent loss of function not related to the patient’s illness or underlying condition.

Root Cause Analysis (RCA): A thorough evaluation by a team involved in an incident aimed at determining the cause of an incident and developing a plan of action to prevent reoccurrence of that type of incident.  RCA’s are required on all Sentinel Events.

Sentinel Event Alert:  Notifications published by TJC to improve the quality of  health care provided to the public.  These publications are posted on the EACH Intranet under Command Publications/Sentinel Alerts and our organization’s response is provide as an attachment.

The Joint Commission

Harm Scale (DoD)