Download - Risk assessment and risk management
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Assessment and Management
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Intro
Whether we like it or not, the community expects mental health clinicians to assess and manage the risks to those in the community posed by patients with a mental illness.
The public is unlikely to accept excuses by the mental health services when failures occur and a person in the community is seriously harmed, no matter how legitimate they may be.
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Intro
In modern culture, greater emphasis is put on the concept of risk, especially in fields concerned with the future consequences of current events. As in business, stock market, investment, politics and psychiatry, all are concerned with methods for better prediction of risk
In psychiatry risk is defined as: The likelihood of an event happening with potentially
harmful or beneficial outcomes for self and others. (possible behaviours include suicide ,self-harm ,self-
neglect ,aggression and violence ;with an additional range of other positive or negative service user experience
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Types of Risk
Of suicide Of aggression Of neglect
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Types of risk (others)
Self injury Other self harm (e.g eating disorders
Abuse by others
Abuse to others Harassment by others
Harassment to others
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Types of risk (others)
Risk to children
Non-violent sex offence
Financial exploitation
Arson Accidental fire risk
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predictors 1. For Risk of neglect
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Neglect
Despite being under estimated ,this category is with the
highest incidence rates in mental health service .
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Neglect
Prev His of neglect
Unable to feed himself
Poor physical health
Poor living conditions
Lack of basic amenities
Poor social support
Inability to maintain hygiene
Financial difficulties
Cant communicate needs
Deny his problems
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predictors 2. For Risk of violence
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Static predictors:
Young Unemployed Early maladjustment
Substance use
Previous violence
Personality disorder
psychopathy Relationship instability Major mental
illness
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Dynamic predictors
Current active substance
abuse Threats Irritability
Lack of insight Negative attitudes Active
symptoms of mental illness
Non response to rx impulsivity
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External predictors
- Are the easiest to change - influenced by the dynamic
psychosocial environment of the person,
- the occurrence of things that will alter the persons view of the world , the people they relate to and their situation
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Protective predictors
Strong social support
Engagement with service
Good social relationships
Stable employment
Prolonged abstinence
from substance Older age
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Staff predictors
Research has shown that inexperienced staff and those with little training in psychiatric care and management of aggressive patients are at an increased risk of being the victim of assault . Staff satisfaction with their working conditions, colleagues, and mangers has also been shown to be associated with lower rates of aggression and violence on inpatient units
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predictors 3. For risk of Suicide
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Demographic predictors
male Increasing age
Low socio-economic Single
Living alone unemployed
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Background history
Deliberate self harm
Childhood adversity (eg sexual abuse)
Family history of suicide
Family his of mental illness
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Clinical history
Diagnosis of mental illness
Personality disorder
Physical illness (chronic painful
disabling)
Recent contact with psychiatric
service
Recent discharge from
in-patient
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Psychological factors
Hopelessness Impulsivity
Low self esteem Life event
Relationship instability
Lack of social support
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Current (context )
Suicidal ideation
Suicidal plans
Availability of means
Lethality of means
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Risk assessment
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Risk Assessment
The purpose of risk assessment in the inpatient setting is not to predict risk per se, but to identify factors that may indicate risk is elevated and enable a clear and valid risk management plan to be developed
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Risk Assessment Sources include : Health Record Discharge summaries Admission assessments Reports Mental Health Act documentation Correspondence from other agencies or individuals
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Risk Assessment Sources include : Criminal Offence History and Charge Summaries School reports collateral info (often missed ) Relatives, carers,
General Practitioner and other agencies such as the Police or Ambulance
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Risk Assessment For each episode consider either :
5W approach
When the episode occurred Where it occurred Who the victim(s) What behaviour they engaged in What are the consequences Why did they engage in that behaviour
ABC analysis
Antecedents
Behaviour
Consequences
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Risk Assessment Clinical and actuarial approaches to risk assessment : 1. Unstructured clinical method Most risk assessment currently performed by clinical methods ,its based on clinical experience ,individual knowledge and person specific assessment to reach a conclusion (only 1/3 are right !)
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Risk Assessment Clinical and actuarial approaches to risk assessment : 2. structured clinical risk assessment e.g HCR-20 (historical-clinical and Risk) Compromised of 10 historical items ,5 clinical items and 5 risk management items
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Risk Assessment Clinical and actuarial approaches to risk assessment : 3.Actuarial instruments These methods utilise statistical techniques to generate risk predictors. Actuarial risk prediction is primarily based on information about group risk of re- offending, analysed in extensive studies of populations, using meta-analytical techniques.
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Risk Assessment Clinical and actuarial approaches to risk assessment : 3.Actuarial instruments Actuarial assessment of an individual measures how far the individual shares the key characteristics of the group, such as age, gender, criminal records, etc. which are found to be associated with levels of risk.
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Risk Management
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Risk Management Collaborative Vs defensive styles in management
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Risk Management Collaborative Vs defensive styles in management
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Risk Management The whole purpose of a risk assessment is to provide the foundation for and to guide the development of a risk management plan. A risk assessment is never complete without a risk management plan.
Treatment placement Restrictions Implemen
tation Monitorin
g
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Risk Management
Treatment
placement
Restrictions
Implementation
Monitoring
risk management plan addresses
certain static but mainly dynamic risk
factors and capitalises and enhances
protective factors
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Risk Management
Treatment
placement
Restrictions
Implementation
Monitoring
by implementing biological,
psychological and social interventions,
traditionally related to mental health,
such as type, duration and dose of
medication, cognitive behaviour
therapy, social supports and vocational
pursuits
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Risk Management
Treatment
placement
Restrictions
Implementation
Monitoring
Placement is the environment in which the treatment will be carried out or implemented In deciding on placement, the clinician should always consider the least restrictive alternative that enables safe management of the patient. To do this, the clinician must have regard to the identified risk and the treatment required
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Risk Management
Treatment
placement
Restrictions
Implementation
Monitoring
are limitations that are placed on the person in order to make the treatment work in the placement. Restrictions refer to the constraints and coercive mechanisms that might be required to keep the person safe and reduce opportunity to harm others
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Risk Management
Treatment
placement
Restrictions
Implementation
Monitoring
There are three areas of restriction that the clinician could consider: Environmental restrictions (external to the person manipulated by others) Personal restrictions (internal and relies on persons motivation to adhere) Legal restrictions (legislation)
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Risk Management
Treatment
placement
Restrictions
Implementation
Monitoring
Implementation is about identifying and ensuring that someone is responsible for making the risk management plan happen A persons name or title needs to be entered in the file as the identified person responsible for ensuring the recommendations with regard to treatment; placement and restrictions are carried out as well as monitoring
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Risk Management
Treatment
placement
Restrictions
Implementation
Monitoring
is the gathering of information to inform the clinician about and ensure the effectiveness of, treatment, placement, restrictions and implementation.
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Risk Management
Treatment
placement
Restrictions
Implementation
Monitoring
Monitoring involves three things: 1. Gathering additional information
(for example the need to refer for a specialist opinion, getting old notes, meeting with the family).
2. The determination of the effectiveness of the treatment, restrictions and placement.
3. The frequency of reviews, by whom, when and where.
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conclusion We would argue that there are significant reasons for Mental
Health Services to build on their Risk Assessment and Management skills.
For these reasons our assessment processes need to be state of
the art, transparent and evidence based. Risk Assessment and Management should be an integral part of clinical practice
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Thank you
Slide Number 1Assessment and ManagementIntroIntroTypes of RiskTypes of risk (others)Types of risk (others)predictorsNeglectNeglectpredictorsStatic predictors:Dynamic predictors External predictorsProtective predictors Staff predictorspredictorsDemographic predictorsBackground historyClinical history Psychological factorsCurrent (context )Risk assessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementconclusionThank you