What is Clinical Risk Management?

Page contents: Background | Auditor General’s Report Managing patient safety in public hospitals March 2005 | Local Hospital Based CRM Programs | Statewide Reporting of Sentinel Events

Background

Adverse events and medical error in health care have been recognised as an important public health problem. In the past ten years, studies including The Quality in Australian Health Care Study have attempted to quantify and qualify adverse events using similar methodology. These studies have provided an important contribution in determining the frequency, nature and causes of adverse events.

Given the complexity of the health care system, preventing adverse events and improving patient safety requires a multifaceted approach. While the Government is committed to improving patient safety in Victorian hospitals, a great deal of the responsibility for achieving results will rest with hospitals and clinicians. Implementation of local hospital CRM programs contributes to a necessary change in adverse event management and the acceptance of CRM as an integral part of routine hospital functioning.

Auditor General’s Report Managing patient safety in public hospitals March 2005

The Clinical Risk Management Strategy (CRM) strategy has been in place since 2001-2002, its primary target was preventable adverse events and to encourage a systems approach in examining contributory factors leading to these events. The strategy focused on the conditions under which adverse events occurred, and where the investigation of these events is seen as an opportunity to improve practice and patient safety.

In 2005 the Auditor General’s office undertook a review of the effectiveness of the arrangements health services have in place to identify, investigate, address and prevent clinical incidents.

The report has made recommendations to both DHS and health services to improve performance in this area. The report and recommendations are available at the Victorian Auditor-General's Office website. (external site)

Work will be undertaken in 2005-06 to address recommendations made within this report.

Local Hospital Based CRM Programs

Statewide Reporting of Sentinel Events

The Department has also established a statewide system for reporting against a subset of adverse events called Sentinel Events. All hospitals must report Sentinel Events to the statewide Sentinel Event reporting system.

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