Integrated management of clinical risks
Letter to the Editor

Integrated management of clinical risks

Ana Isabel Fernández-Castelló1, Laura Alvargonzález Slater2, Luis Manuel Arnáiz Aparicio3

1Quality and Clinical Risk Director, Bupa Europe and Latinamerica, Madrid, Spain; 2Nursing Director. Moraleja Sanitas Hospital. Madrid, Spain; 3Medical Director, Moraleja Sanitas Hospital, Madrid, Spain

Correspondence to: Ana Isabel Fernández Castelló. Quality and Clinical Risk Director, Bupa Europe and Latinamerica, Ribera del Loira, 52, 28042 Madrid, Spain. Email:

Response to: Park SJ. Sharp AL. Improving health and health care efficiency through risk Management. J Hosp Manag Health Policy 2019;3:9.

Received: 24 November 2019; Accepted: 04 February 2020; Published: 25 March 2020.

doi: 10.21037/jhmhp.2020.02.02

Over the last 20 years, and since the publication of “To Err is Human: Building a Safer Health System” (1), many strategies have been implemented and much effort invested to minimise the risk of adverse events occurring.

Although the advances made have been numerous, the ambition of obtaining total safety has not been achieved (2). Amalberti and Vicent argue that patient safety is a constantly moving target. Its limits have been increasing over time due to the inclusion of new forms of harm within the area of safety (3,4). New technologies and models of healthcare provision, the transformation of fatal diseases into chronic illnesses, improvement in standards and the increasing concern about safety, among other aspects, have been key in the evolution of patient safety issues.

This changing environment, which undoubtedly provides advances and benefits, also gives rise to new forms of risks which need to be tackled. Vincent and Amalberti (2,4) propose continuing to work, innovate and improve the system, as has been done to date albeit, in parallel, developing and implementing strategies to proactively manage the risk which will help to cope with this environment of constant pressure and change.

This proactive approach is already beginning to be applied in the healthcare setting. Different studies (5-7) demonstrate that this approach is being used on a partial basis given that greater emphasis is being placed on identifying the clinical risks than on the governance system and the risk management framework. However, these last two aspects are key in this process. Therefore, it is not surprising that the aforementioned studies point to situations such as lack of support from senior management, the limited culture and time shortages of professionals and the absence of tools to simplify the work, among other things, as being limitations and barriers to the implementation of the proactive approach.

Managing risks goes beyond identifying a list of risks that affect the organisation. It also encompasses strategy, governance, culture and measuring performance. Furthermore, it is a system for monitoring, learning and ongoing improvement (8).

The Committee of Sponsoring Organizations of the Treadway Commission defines (8) risk management as “a process, effected by an entity’s board of directors, management and other personnel, applied in strategy setting and across the enterprise, designed to identify potential events that may affect the entity, and manage risk within its risk appetite, to provide reasonable assurance regarding the achievement of entity objectives”.

The governance system establishes responsibilities at all levels of the organisation and the culture refers to desired behaviour and awareness of the risks. The strategy and objectives make it possible to bring all functions and levels into line to achieve the same end. Identifying and evaluating the risks that can affect performance makes it possible to anticipate and implement measures to avoid them. Lastly, the continuous monitoring and information process facilitates improvement.

Taking into account the aforementioned premises, the implementation of an integrated risk management system with all its principles could help to overcome the barriers to implementing proactive systems to improve patient safety, as it addresses responsibilities from senior management to any member of staff, the culture and performance, and it is in itself a tool for managing risks and ensuring the achievement of objectives in the organisations.

At British United Provident Association (BUPA), all the risks, including clinical risks, are addressed using an integrated risk management system based on (9): (I) the governance structure, (II) the risk management framework, and (III) the management of the risks itself. The latter is a continual process which includes identifying, evaluating, managing, monitoring and reporting the risks.

In order to make it easier for frontline health professionals to identify and evaluate the clinical risk, a catalogue has been developed at BUPA Europe and Latin America of potential clinical risks that professionals could face in their daily work. The document, which includes the catalogue and its implementation methodology (10), has been made available to the scientific community given that it can be of use in managing risk in any healthcare organisation, whether public or private.


To healthcare professionals of the Sanitas La Moraleja Hospital, Sanitas La Zarzuela Hospital and Sanitas CIMA Hospital. The team of professionals from the Quality and Clinical Risk department of Bupa Europe and Latin America.

Funding: None.


Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Hospital Management and Health Policy. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See:


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  10. Fernandez-Castelló AI, Valle-Pérez P. Catalogue of potential clinical risk for risk management in hospital care. J Healthc Qual Res 2019. Available online:
doi: 10.21037/jhmhp.2020.02.02
Cite this article as: Fernández-Castelló AI, Alvargonzález Slater L, Arnáiz Aparicio LM. Integrated management of clinical risks. J Hosp Manag Health Policy 2020;4:9.

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