BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure

BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure

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BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure

Student Name

Capella University

BHA-FPX4004 Patient Safety and Quality Improvement in Health Care

Prof. Name


Part One: Purpose Statement of Risk Management Policy and Procedure

The objective of this policy and procedure is to establish a secure environment for both patients and employees by:

Risk Elimination, Reduction, and Management: Identifying, minimizing, and managing threats and vulnerabilities to patients and the hospital’s information systems and applications.

Optimizing Care Delivery: Maximizing opportunities for delivering optimal care while minimizing adversities.

Enhancing Patient Safety: Identifying, resolving, and preventing potential risks throughout the hospital’s departments, with a central focus on patient safety and care.


Risk Prevention: Precautionary measures taken to halt foreseeable risks (Hofmann & Scordis, 2018). Example: Quarterly and Annual review of Hospital Emergency Procedure manuals.

Risk Reduction: Decreasing the likelihood of risk occurrence (Hofmann & Scordis, 2018). Example: Mandating proper hand hygiene to reduce hospital infections.

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.

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.

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).

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).


References follow APA formatting style.

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. Retrieved from

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. Retrieved from

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.

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.

BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure

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.


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. Retrieved from

BHA FPX 4004 Assessment 2 Risk Management Policy and Procedure

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

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