The Register That Says Nothing About Safety
Ashcombe Trust is nine months from deploying a new electronic patient record (EPR) across three hospitals. Its risk register contains 60 entries. The top risk, 'clinician adoption failure', is scored 16 on a 5 x 5 matrix and owned by 'IT programme board' rather than an individual. Its only mitigation is 'communications plan', with no actionee or date. The assessment workshop used impact definitions that cover financial loss and reputation but not patient safety. A near-miss at a neighbouring trust, where medication alerts were overridden after go-live, is recorded in a separate lessons-learned log and has not been added to the register. The programme manager says, 'Risk management is done - we have a register and a monthly review.' Clinical directors say they have not been asked to contribute. The board wants assurance that safety risk is being managed before go-live.
1. Evaluate the identification, assessment and planning of the top risk. What process failures does the scenario reveal?
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Identification
Identification has been narrow and programme-centric. Clinical directors were not involved, so the risk is framed as IT adoption rather than safe clinical use. The neighbouring trust's near-miss is exactly the kind of external lesson that should inform identification; keeping it in a separate log breaks the link between learning and risk. No systematic identification across clinical pathways, prescribing, medication administration and escalation has been described.
Assessment
The impact definitions omit patient safety, so a score of 16 understates the risk. The assessment cannot distinguish a communications problem from a medication-safety problem. There is no rationale for probability, no assessment of control effectiveness, proximity or velocity, and no appetite test. 'IT programme board' is not a risk owner: accountability must sit with a named individual who has authority and resources.
Planning
The 'communications plan' is an activity, not a response. It has no actionee, date, success criterion or contingency. There is no go-live readiness gate, no simulation or usability testing, and no trigger for escalation if adoption metrics are poor. The monthly review is a ritual unless it challenges evidence.
The process steps exist in form but not in substance. The programme manager is measuring the existence of a register, not the management of risk.
2. Rewrite the top risk entry so that it would meet M_o_R Practitioner expectations. Include owner, actionee, assessment rationale, response and review trigger.
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Revised risk entry
Risk statement: Failure to achieve safe and sustained clinician adoption of the EPR in clinical areas by go-live, leading to workarounds, medication-alert override and patient-safety events.
Risk owner: Chief Nursing Information Officer - accountable, with authority to direct clinical engagement and escalate to the trust board.
Risk actionee: Clinical Adoption Lead - responsible for implementing the response and reporting progress.
Assessment: Probability 4/5, impact 5/5 on patient safety; score 20. Rationale: the neighbouring trust's alert-override near-miss, low simulation uptake in two directorates, and known usability concerns in medication alerts. High velocity and proximity: go-live is nine months away. The safety impact exceeds the trust's stated appetite, so board escalation is required.
Response - mitigate: clinical champions in every directorate; mandatory simulation for prescribers; pharmacy-led usability testing of medication alerts; go-live readiness criteria including 90% training completion and an alert-override audit; a stop/go gate six weeks before go-live.
Review trigger: monthly programme board; after each simulation cohort; after any safety incident or near-miss; immediate escalation if readiness criteria are not met. The entry also links to the lessons-learned log and records the source of the near-miss evidence.