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Managing and Mitigating Risk: An Administrator's View

April 1, 2006
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Learn from this administrator's negative experiences with risk issues-and his positive resolution by Victor Lane Rose, MBA, NHA
As liability issues abound and insurance premiums skyrocket, risk management is no stranger to long-term care managers. Several areas of long-term care are particularly susceptible to serious risk exposure (see "Typical Risk-Associated Events"). Many organizations are cognizant of this but have struggled to fully understand this complex topic and how to implement an effective risk-management program. Because issues of risk are multifaceted, they require an equally complex and systemic approach. Effective risk management is a way of conducting day-to-day operations, encompassing preplanning to prevent risk-laden situations and implementing procedures to follow when things go wrong, as they inevitably will. At the heart of a successful approach is an acknowledgment that organizations, like people, are more often judged by how they handled a mistake, not whether one was made.

Case One
One of the hardest situations for a long-term care employee to deal with is a missing resident. The person who made the discovery must make immediate decisions having implications for the suspected missing resident, the resident's family, the organization and, potentially, the outside community's emergency-response systems.

One such occurrence at my own facility began with a phone call notifying me that one of our more "independently minded" residents, who had a history of taking walks without following checkout procedures, was missing. Employees conducted an extensive search of the building and grounds, contacted family members, and then telephoned authorities. As I drove up to our facility, I experienced a wide range of emotions. I was awestruck as I negotiated a full contingency of emergency-response vehicles crowding our parking lot. I identified myself to the largest congregation of uniformed personnel, who were busy planning search patterns. I was informed of the search status, including the fact that a state police search helicopter was in flight.

As it turned out, the resident had gone to an evening service at his church. While this was a documented "near miss," the incident unleashed a chain of events with far-reaching ramifications for our facility. It would have been easy to treat the employee who made the decision to contact authorities as if she had overreacted, but that would have diminished employees' willingness to make critical decisions in the future. Her response was correct for the situation she faced. We recognized her conduct as such, reemphasized to the resident the responsibilities of residency, and extended formal appreciation to our local, county, and state emergency responders. Meanwhile, we sent risk-management bulletins to residents, family members, and employees, reiterating our sign-out procedures and that we are developing a system of missing-resident drills for staff.

Case Two
Even if blessed with the most knowledgeable employees, the finest policies and procedures, the most realistic expectations, and the highest levels of trust, we are not capable of overcoming one of the most basic truths of our human condition: We are imperfect beings, and we make mistakes. Best practices don't promise an absence of risk; they promise an ongoing commitment to responsively minimize risks associated with the aging process.

One morning, I arrived at work to find one of our residents in cardiac arrest. Asked to continue CPR in the ambulance during transport to our community hospital, I waited near the nurses' station at the ER for a report. Eventually I learned that the resident had passed away, and as my thoughts returned to work I became aware of a conversation behind me.
I heard a nurse on the phone ask in disbelief, "You did what?" She told a nearby ER physician about the information she just received, and his face flushed with anger. Having heard her mention my facility, I quickly walked over and interrupted the discussion by introducing myself. Thrusting the phone toward me, she said, "Here, you talk to her."

The caller was one of our charge nurses, who began by reminding me that we had many residents with the same first and last names, distinguishable only by their middle initials. She recounted that the employee who had contacted the resident's family had accidentally grabbed the chart of another resident-and the wrong family was en route to the hospital, thinking that their mother had passed away. It also meant that the relevant family remained wholly unaware of the morning's events. I instructed our charge nurse to immediately contact the family whose mother had died and explain the course of events.

Confident that amends would be made with the grieving first family, I told the physician I would meet the arriving family in the lobby to explain our facility's mistake. Following this difficult but ultimately positive encounter, I returned to our facility. As I entered, I saw the employee who had made the mistake waiting in the hallway. Stricken with grief, she ran to me and asked me to write her up. But instead of a disciplinary action, I suggested that both families deserved a personal apology for her mistake. Having to face both families would be more difficult for her than any discipline I could dole out.