Risk Management and Patient Safety in a Hospital

This essay will present an interaction that took place in practice that captured the multi-disciplinary team discussing a service user. This interaction shows the concept of risk management, patient safety and leadership within a hospital setting. These concepts will be explored and critically reviewed to establish how important leadership and advocating for a service user is. It will also demonstrate how important a good multi-disciplinary team can work together for patient safety with least restrictive practice.

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Interaction in practice

A mixed 20 bedded ward in acute mental health for adults aged 18 to 65 received an informal admission which is lease restrictive practice (Scottish Government, 2006). The service user has a diagnosis of borderline personality disorder who was known to staff on shift. As it was a weekend none of the service user’s medical team was on shift, which meant they would meet with the duty doctor, and duty consultant. The duty consultant arrived and went to one of the interview rooms to chat with the service user. On return the consultant stated that the service user would stay until they met with their own team. When asked about passes off the ward the consultant said nurse escort passes only. The coordinating nurse then stated that this would not be acting in the service user’s best interest and history has proved this to be non-beneficial. The nursing multi-disciplinary team (MDT) then proceeded to state the service user was informal and attended voluntary. This will cause distress and anxiety to service user when staff cannot facilitate the time off the ward.

The consultant stood by his recommendation but the coordinating nurse got in touch with the coordinating charge nurse (CCN) and pursued the decision. It was then talked over by the coordinating nurse, consultant and CCN as well as the staff on shift. After the MDT had discussed the matter the result ended with the service user gaining 15 minutes passes which worked out well over the weekend for the service user.


The definition on leadership is one in a position or function as a leader to direct or guide a group or party (Waite and Soanes, 2007). Nicolson et al, (2011) states there is more ramification with being a leader such as: communication, emotions, and the relationship between followers and the leader. However if professionals in a leadership role are not performing to the high standard this can impact on the team reducing their commitment to the care and treatment of service users (Kilfedder, Power and Wells, 2001).

Researchers have not only been tasked with finding a definition for leadership but also evidencing the characteristics that make a good leader.

(Wangensteen, Johansson, & Nordstrom, 2008) state that an individual constantly producing a high level of practice above recommended standards as well as displaying a caring interest in other colleagues performance, and sharing information or guidance at the correct time has all the characteristics of a leader.

Professional socialization according to (Clearly et al. 2011) states leaders will engage in conversation to explore values, beliefs and attitudes of individuals they work with as well as initiating team building interactions and offering support towards the team members.

Alimo-Metcalfe (2003) states that individuals are most effective when they are competent and confident and aware of their own strengths and behaviours and can work well with other team members. This was displayed in the scenario as the coordinating nurse was confident and showed their strength by pursuing the matter with the backing of the MDT.

(Hogan, 1994) states leadership is persuading colleges to set aside individual concerns for a short period of time to support a mutual goal or responsibility for safety and welfare of a group.

On the other hand (Fowler, 2012) states leadership is projected through role modeling. Role modeling according to (Fowler, 2012) is an individual who is “good at their job” and competent within their role with the ability to carry out tasks with ease. However there are some clinicians that practice on the edge within ethical dilemmas that could be deemed unprofessional therefor would not make good role models.

(Bosman et al. 2012) also agrees with role modeling and its importance with leadership and states there are four aspects that experienced members of a team lead from. These are inspiration and motivation, self-efficacy reinforcing junior’s beliefs to achieve more. Learning by example of real life practice situations and a support for other members of the team.

The leadership skills displayed in the scenario above was to advocate for the service user and be their voice. This took confidence and knowledge with a compassionate and empathetic approach so the service user would not be distressed or agitated over the weekend. It also demonstrates how connected the team was to get involved in the discussion to reinforce the initial statement. By displaying communication skills and introducing an outside party to evidence reasons why this would be the best course of action for the service user the pass was granted, and there were no incidents over the weekend involving the service user.

However the service user could have went out on pass and not returned and the scenario could have been much worse even disastrous. But the staff member had evidence based knowledge about the individual and practical experience with care and treatment for the service user. Although there was a risk with this scenario all parties were following the 10 essential shared capabilities (ESCs) by working in partnership, promoting recovery, providing service user centred care, making a difference and positive risk taken (Anderson and Burgess, 2009) this guided all members to reach a decision.

Kean and Haycock-Stuart (2011) argue that policies and interactions put in place to deliver a high standard of care can suggest that the individual in the leadership role is solely responsible for its success. This singular approach fails to report the relationship between the leader and followers and the prevalence of the followers contributions (Kean and Haycock-Stuart, 2011).

The Scottish Government (2009) acknowledges that the leadership development for National Health Service (NHS) Scotland is achieving its goal. This is regarded as a priority for (NHS) Scotland and is prioritized at a local level (The Scottish Government, 2009). This has been introduced to insure healthcare professionals can practice nationally and local with leadership qualities and behaviours to deliver a high standard of care that is safe and effective. Policy within (NHS) Scotland states all employees are made clear and understand exactly what their role is. As they have a duty of care to provide the best care possible, and leaders have the responsibility to ensure this is happening to the correct standards but allow participation in the decision making process (The Scottish Government, 2009). The NHS has a model (Leading Better care, 2011) that can direct leaders to consider leadership qualities and develop positive attitudes and set out goals. How leaders behave within National Health Service (NHS) Scotland can make or break their agenda for health care.

Research suggests that an effective leader can have a positive impact on service user care. There has been many cases of bad practice in healthcare that has been publicized for the public such as; The Mid Staffordshire NHS Foundation Trust which produced the Francis Inquiry (Nolan, 2013) which explored what happened and were the trust failed. The report stated that all healthcare workers working within the health care system will be held accountable for their actions and the care they provide. The report addressed staff from all positions especially senior positions who neglected their basic leadership skills (Nolan, 2013).

(Blegen and Severinsson, 2011) state mental health nurses are always advancing their practice with change while working in environments that are challenging. By developing leadership skills that are motivating and encouraging colleagues to work responsibly and respectively with service users. This demonstrates the importance that leadership skills have when tasking or directing a colleague to have reassurance the task will be carried out correctly (Cleary et al. 2011). This can depend on the relationship of the followers and the leaders as this has an important bearing on the success of the healthcare environment. However (Kean and Haycock-Stuart, 2011) states that the followers are over looked as the framework for leadership focuses on the leaders as individuals. Kean and Haycock-Stuart (2011) state there is more to being a follower than following a leader, if judgements are made that disagree with a leader this can make or break the relationship of leader and follower. Good leadership takes opinions into consideration and work with reciprocity built on trust (Kean and Haycock-Stuart, 2011).

Along with leadership is patient safety as described in paragraphs above leadership has been the emphasis for NHS Scotland locally and nationally but these two concepts work in partnership with each other (The Scottish Government, 2010). The Nursing and Midwifery Council (NMC) acknowledge the importance for individuals to continually update skills and experience in leadership and patient safety and working in partnership with universities have implemented a new domain constructed for leadership. This domain will be part of student competencies that will be expected to be adhered to when they become registered nurses. Registered nurses must now lead and challenge in a bid to improve services to provide the best possible care (NMC, 2010).

Patient Safety

Safety is the most important part of the healthcare service, safety for service users and safety for healthcare professionals. The drive for safety within the healthcare services are one of the three ambitions by the Scottish Government which will strive to deliver and support safe and effective healthcare. All service users will receive care and treatment in a clean, safe environment free from preventable harm or injury in any NHS Scotland healthcare facility (Scottish Government, 2010). Patient safety is the foundation that nurses construct their practice around and is a professional value that the Nursing and Midwifery Council stipulate is a requirement with the code of conduct (NMC, 2015). All registered nurses must safeguard the health and well-being of all individuals for as long as there are receiving care (NMC, 2008).

Ferguson et al. (2007) states when patient safety is compromised and errors transpire the role of the clinical practitioner can be scrutinized when there are numerous factors that threaten patient safety. Some factors such as; work load pressures and staff shortages can count for miner mistakes happening within the healthcare system. However (Ferguson et al, 2007) also states good communication within a positive and motivated working team are factors that are effective in building a good safety culture.

General hospitals are subjected to the same safety risks with patient safety as in a mental health hospital such as; pressure sores and medication errors. However, additional risks to staff and patients are unique in the mental health area (Bark and Tingle, 2011).The management of violence and aggression and the use of seclusion are to support patient safety as mental health hospitals use restraining techniques which can increase the service user’s vulnerability. However mental illness can cause individuals to become suspicious, disorientated, paranoid or delusional that can cause anger or difficulty with instructions (Bark and Tingle, 2011). This can generate a more complex case for patient safety even though risk assessments are carried out daily within mental health wards. Staff predicting and planning for every preventable event that could happen, due to human behaviour is only effective with the information they possess at that time (Tate and Feeney, 2012).

Langan (2010) states that violence in a mental health facility with service users were a risk may be prevalent to themselves or to staff, argues that this can exacerbate anxiety and increase pressure that is required when assessing a service users risk. Service users can be unpredictable when first presenting and with lack of knowledge of what is happening for that service user at that time presents numerous changeable factors that can transpire (Langan, 2010). There has been many attempts to build an assessment tool for mental health services but they have failed to reach the standard required (Langan, 2010).

(NHS Lothian, 2012) state that the policy within mental health for risk assessments must be carried out for every service user that is admitted to hospital and becomes an inpatient this should be in conjunction with the service user. When filling out the risk assessment current information should be included such as; relevant history, associated behaviours, clinical diagnosis and information from the service user’s perspective as well as information from family this will ensure a robust risk assessment and support patient safety (NHS Lothian, 2012). A risk assessment is always being amended and is never complete it is an ongoing procedure that is effective at the time it is carried out (Tate and Feeney 2012). Risk assessments that are updated daily support patient safety. The mental health setting can highlight complexities with patient safety and emphasises how staff work in partnership with service users and using reciprocity keep patients safe (Tingle and Bark, 2011).

When managing patient safety within the scenario this can present challenges as the coordinating nurse was basing her evidence on previous history but had a good knowledge and rapport with the service user. By working in partnership with the service user and promoting recovery on previous admissions the nurse already had a basic plan for a risk assessment and was thinking of patient safety and what could have transpired if the passes were not granted. However ever admission is different so nothing should be assumed for example; that last admission the service user got aggressive, that does not mean this will happen this admission.


The scenario that was introduced was not uncommon at the week end for an inpatient in mental health services. The service user could have had a different scenario if that individual was not on shift advocating for the patient and displaying leadership qualities. By checking legislation, frameworks, local policies and training which is available to support staff to deliver a high standard of care and ensure patient safety.

By understanding what traits aid with leadership and just how important the skills to lead are and developing and nurturing them to provide a high standard of care from you and your team.

Patient safety will always be identified as an important part of healthcare and by carrying out risk assessments will insure service user receive the best care for them. For more complex situation within mental health settings staff must follow polices and legislation and support each other fully as a team and with proper planning and applying daily risk assessments can support in minimizing harmful events from transpiring.


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Preserve safety