BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure

BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure

BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure


Capella university

BHA-FPX4004 Patient Safety and Quality Improvement in Health Care

Prof. Name


Part One: Risk Management Policy and Procedure Purpose Statement

The purpose of this policy and procedure is to establish an environment of safety for both our patients and employees by:

  1. Risk Elimination, Reduction, and Management: To identify, reduce, and manage threats and vulnerabilities to patients, as well as to the hospital’s information systems and applications.
  2. Optimizing Care Delivery: To maximize opportunities for delivering optimal care while minimizing adversities.
  3. Enhancing Patient Safety: To identify, resolve, and prevent potential risks throughout the hospital’s departments, with a central focus on patient safety and care.


  1. Risk Prevention: Precautionary measures taken to cease foreseeable risks (Hofmann & Scordis, 2018). Example: Quarterly and Annual review of Hospital Emergency Procedure manuals.
  2. Risk Reduction: Decreasing the probability of risk occurrence (Hofmann & Scordis, 2018). Example: Mandating proper hand hygiene to reduce hospital infections.
  3. Regulatory Compliance: Adherence to policies, laws, or recommendations for appropriate healthcare guidelines and operational practices (Dückers et al., 2009). Example: Adhering to TJC’s patient safety procedure of proper patient identification.
  4. Patient Safety: Initiatives and protections in healthcare aimed at averting adverse harms towards patients (Dückers et al., 2009). Example: Ensuring all bed rails are in the upright position to protect patients from falls.
  5. Adverse Event: Incidents resulting in harm to a patient, hospital employee, or visitor. Example: Patient slip and fall due to a wet spot on the floor (Dückers et al., 2009).
  6. Near Miss: A prevented harm that could have resulted in needless harm to a patient, employee, or visitor (Dückers et al., 2009). Example: A nurse noticing a discrepancy in patient information before administering medication.

Risk Categories and Identification Techniques

  1. Legal and Regulatory Compliance: Measures taken to adhere to healthcare policies and laws (Lee, Chang, & McCombs, 2019). Example: Compliance with the federal 340B Drug program.
  2. Clinical and Patient Safety: Focus on patient safety initiatives and reducing patient fall numbers (Nedved et al., 2012).
  3. Technology Integrations: Implementing preventive measures to protect against cyber attacks (Ayatollahi & Shagerdi, 2017).
  4. Infectious Disease Preparedness: Strategies to protect employees and patients from infectious diseases (Rebmann, Carrico & English, 2007).

Risk Management Strategies

  1. Employee Education: Annual training modules on risk management strategies.
  2. Documentation: Complete and accurate documentation of all risk occurrences.
  3. Departmental Preparedness: Promoting departmental cohesiveness on best practices.
  4. Patient Concerns: Investigating and resolving patient concerns.
  5. Participation in Surveys: Participating in state, federal, or regulatory surveys (Ayatollahi & Shagerdi, 2017).

Risk Categories

  1. Cybersecurity: Protecting patient health information and hospital data (Ayatollahi & Shagerdi, 2017).
  2. Health Information Management (HIM): Managing compliance and preventing coding vulnerabilities (Scott, 2015).
  3. Billing and Collections: Ensuring error-free billing to avoid denials in claims (Scott, 2015).

Risk Manager Role

The Risk Manager is responsible for implementing programs and policies to identify, evaluate, and prevent risks throughout the hospital system (Seckel, 2013).

Part Two: Application of Risk Management Principles

The potential risk being analyzed is Patient Identification Errors. These errors can disrupt patient care and lead to unnecessary harms (Clancy, 2005).

Risk Identification

Strategies for identifying patient identification errors include hospital-wide audits and frontline staff education (Thomas & Evans, 2004).

Risk Reduction and Elimination

To reduce patient identification errors, changes to current processes, employee trainings, and IT safeguards are recommended (Cunningham, 2012).


Effective risk management policies can enhance patient safety and reduce errors (Benson, 2017).


Ayatollahi, H., & Shagerdi, G. (2017). Information Security Risk Assessment in Hospitals. Medical Informatics Journal, 11, 37–43.

Benson, E. (2017). Mismatched How Patient Identification Errors Are Costing Patients And Health Systems. Health IT Outcomes.

Clancy, C. M. (2005). AHRQ Quality and Safety Initiatives. The Joint Commission Journal on Quality and Patient Safety, 31(6), 354–356.

Cunningham, B. (2012). Positive patient identification begins at step one. Health Management Technology, 33(8), 10-11.

Hofmann, A., & Scordis, N. A. (2018). Challenges in Applying Risk Management Concepts in Practice: A Perspective. Risk Management and Insurance Review, 21(2), 309–333.

Lee, C., Chang, J., & McCombs, J. (2019). Specialty Drug Price Trends in the Federal 340B Drug Discount Program. Journal of Managed Care & Specialty Pharmacy, 25(2), 178–187.

BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure

Nedved, P., Chaudhry, R., Pilipczuk, D. & Shah, S. (2012). Impact of the Unit-Based Patient Safety Officer. JONA: The Journal of Nursing Administration, 42(9), 431–434. doi: 10.1097/NNA.0b013e318266810e.

Rebmann, T., Carrico, R., & English, J. F. (2007). Hospital infectious disease emergency preparedness: A survey of infection control professionals. American Journal of Infection Control, 35(1), 25–32.

Scott, P. (2015). Executive Perspectives on Top Risks for 2015. EDPACS, 51(6), 8–11.

Seckel, M. A. (2013). Maintaining urinary catheters. Nursing, 43(2), 63–65. nurse.0000425872.18314.db

BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure

Thomas, P., & Evans, C. (2004). An Identity Crisis? Aspects of Patient Misidentification. Clinical Risk, 10(1), 18–22.

WHO. (2007). WHO: Identification Patient Safety Solutions. WHO Patient Safety Solution; Volume 1.

Wilson, C. (2016). Patient ID Errors Happen—and they can be deadly. Health Exec;