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Clinical tip - clinical risk assessment

Posted on 16/11/2016 by David Rennie

Clinical risk assessment is defined as 'the systematic collection of information to determine the degree of harm (to self or other) that is likely at some point in time'

As a nurse we must always be aware of our clinical responsibilities to ensure that we provide the safest possible care (and environment) to our service users. Often our service users are adults who are extremely vulnerable and can be exposed to risks of harm to others, suicide/self-harm, and self-neglect.  As a nurse, you should be mindful of these risks when responsible for a clinical area.

Clinical risk assessments can be carried out when assessing the risks/needs of your clinical environment, your service user group, or even on an individual basis. You may already be carrying out clinical risk assessments without even realising.

Clinical risk assessments can be completed by using the tried and tested clinical risk assessment process of:

  • Assess – What’s the diagnosis of your service user group? Are there specific risks or hazards that need to be identified? Do you have any service users that are at risk? What could go wrong?
  • Plan – Identify what control measures are already in place. Are they adequate? What else is needed to limit the risk?
  • Implement – Put your plan into action. Communicate and inform all relevant parties.
  • Evaluate – Review whether your control measures are minimising or controlling the risk.
  • Record – As always, write it down and make sure everyone that needs to know is informed!

A basic example from an EMI unit perspective could be:

  • Assess – You work with a confused, elderly resident who can occasionally be physical violent.
  • Plan – Inform your staff team of the potential risk of violence. Ensure observations and plan is in place.
  • Implement – Instruct your staff team to be aware of the potential risk to the individual and others.
  • Evaluate – Review how successful the situation was managed
  • Record – As always, write it down and make sure everyone that needs to know is informed! (care plan update and handover details)

This continual process will always require you to be aware of your resident group, your environment, and the staff team working beside you.

The process works for all major and minor risks and can be carried out both formally and informally depending on the risk.  This may already be, or will become, second nature to you.

 

Clinical tip takeaway

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