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Healthcare risk assessment

Internal and Hospital Medicine Risk Assessment: Patient Safety, Handover and Escalation Controls

A worked example of how a teaching team finds, scores and controls risks in general internal medicine and hospital ward care, from delayed deterioration and medication harm to handover gaps, privacy and equipment failure.

Updated November 2026 8 hazards assessed Review every 3 months Highest risk: Critical to Medium
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Executive summary

This assessment shows how a teaching team on a general internal medicine ward can find, rate and control the risks that matter most to patient safety, privacy and continuity of care. Eight risks were chosen because they are plausible in everyday ward work. Failure to recognize deterioration is the highest inherent risk, with medication error, unsafe handover and staffing shortfall close behind. Each risk is scored before controls and again after existing and added controls. Most risks fall to Medium or Low once the additional controls are in place, but deterioration stays at Medium because the harm remains serious. The first actions are a written escalation ladder, structured handover, medicines reconciliation on admission and verified competence for agency staff. The ward is a teaching example, so every score illustrates method, not a real service, and clinical decisions stay with the treating team.

Focus area
Internal medicine and hospital ward care
Setting
Adult general internal medicine ward in a hospital with shared clinical records and on-call medical teams
Method
Five by five likelihood and impact risk register

Scope

This assessment covers the care of adult patients on a general internal medicine ward, from admission and daily review to handover, discharge and the use of clinical records and equipment. It looks at risks to patient safety, privacy, staff competence and continuity of service. It does not cover surgery, intensive care, emergency triage or any real hospital's policies. Jurisdiction, staffing levels and systems are assumptions made for teaching.

Context

The ward has a consultant led team with registrars, junior doctors, nurses, a pharmacist who visits daily, allied health staff and a bank of agency nurses. Patients arrive with multiple conditions, and orders, results and notes are kept in an electronic record with some paper charts still in use. Monitoring equipment such as observation devices and infusion pumps is shared across bays. Each hazard is scored before controls to show its natural level, then again after existing controls and the additional controls that should be added. Clinical decisions remain the responsibility of the treating clinicians.

Objectives, assets and stakeholders

The objective is to deliver safe, timely and respectful care to adult patients, protect their privacy, keep staff competent and supported, and meet professional and regulatory duties. The assets in scope are patients themselves, the clinical record, medicines and clinical equipment, the ward roster and the team's professional reputation. Stakeholders include patients and families, nurses, doctors, pharmacists and allied health staff, agency workers, the clinical governance and information teams, and regulators and professional bodies. Every risk has one owner role, and the clinical lead for the ward reports the register to the hospital governance group each quarter.

Risk matrix: before and after controls

Each cell shows hazard numbers placed by likelihood and impact. Compare the two grids to see how controls move each hazard.

Before controls

Inherent risk

Risk before controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely Likelihood 4, impact 3, score 12, high: H03 H06 Likelihood 4, impact 4, score 16, high: H02 Likelihood 4, impact 5, score 20, critical: H01
3 Possible Likelihood 3, impact 3, score 9, medium: H07 H08 Likelihood 3, impact 4, score 12, high: H04 H05
2 Unlikely
1 Rare

After controls

Residual risk

Risk after controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely
3 Possible Likelihood 3, impact 2, score 6, medium: H06
2 Unlikely Likelihood 2, impact 2, score 4, low: H04 H07 H08 Likelihood 2, impact 3, score 6, medium: H02 H03 H05 Likelihood 2, impact 4, score 8, medium: H01
1 Rare
  • Low 1 to 4
  • Medium 5 to 9
  • High 10 to 16
  • Critical 17 to 25

Hazard register

A summary first, then the detail for each hazard.

Summary of hazards with scores before and after controls
No.HazardBeforeAfterOwner
H01 Delayed recognition of clinical deterioration 20 Critical 8 Medium Clinical lead for the ward
H02 Medication prescribing and administration error 16 High 6 Medium Ward pharmacist lead
H03 Unsafe handover between shifts and teams 12 High 6 Medium Senior registrar
H04 Breach of patient privacy and records 12 High 4 Low Information governance lead
H05 Hospital acquired infection and exposure 12 High 6 Medium Infection prevention and control nurse
H06 Staffing shortfall and unverified competence 12 High 6 Medium Nurse manager for the ward
H07 Equipment and information system failure 9 Medium 4 Low Clinical engineering manager
H08 Consent and documentation gaps 9 Medium 4 Low Clinical governance lead
H01

Delayed recognition of clinical deterioration

Safety Before 20 After 8

A patient's worsening observations, falling urine output or new confusion are missed or not escalated in time, so treatment starts late and the patient may need intensive care or die.

Who or what is affected: Admitted patients, nursing and medical staff, families

Causes

High patient numbers, unclear escalation routes, and scores that are charted but not acted on by busy staff.

Consequences

Avoidable cardiac arrest, unplanned transfer to intensive care, prolonged stay and serious harm or death.

Existing controls

  • Observations are charted at set intervals using a recognized early warning score.
  • Nurses call the medical team when a score passes the agreed trigger.

Control gaps

Escalation depends on individual judgment, and no one checks whether triggers were met when staff were short.

Additional controls

  • Prevent: Set a written escalation ladder with named contacts for every score band and audit it monthly.
  • Detect: Review missed observation sets and late escalations at each shift handover and record them.
  • Respond: Require a senior review within a fixed time after any score in the highest band.
Likelihood 4 x impact 5 before; 2 x 4 after Owner: Clinical lead for the ward Target: Within 30 days Early warning: Observation sets that are missed, or a score that rises twice without a documented senior review.
H02

Medication prescribing and administration error

Safety Before 16 After 6

A wrong dose, wrong drug, missed allergy or harmful interaction is prescribed or given, often because the medicines list is incomplete or orders are unclear.

Who or what is affected: Patients, prescribers, nurses and pharmacists

Causes

Incomplete medicines lists, handwritten or unclear orders, weekend cover and frequent changes in therapy.

Consequences

Adverse drug reaction, organ injury, prolonged stay, complaint and the need for open disclosure to the patient.

Existing controls

  • Prescriptions are entered electronically and checked by a pharmacist on the ward each weekday.
  • Nurses scan the patient wristband and the medicine before administration.

Control gaps

Reconciliation is sometimes done after the first dose, and high risk drug checks are not recorded consistently.

Additional controls

  • Prevent: Require a documented medicines reconciliation within 24 hours of admission for every patient.
  • Detect: Review high risk drug orders and near misses in a weekly safety huddle.
  • Recover: Keep a clear procedure to report, treat and disclose an administration error to the patient.
Likelihood 4 x impact 4 before; 2 x 3 after Owner: Ward pharmacist lead Target: Within 30 days Early warning: Medicines reconciliation not completed within the agreed time for a patient on more than five regular drugs.
H03

Unsafe handover between shifts and teams

Operational Before 12 After 6

Key information about a patient's plan, pending results or risks is lost when staff change, so tasks are missed or repeated and the next team acts on out of date facts.

Who or what is affected: Patients, incoming and outgoing teams, and covering staff

Causes

Shift changes, interruptions during handover, and different formats used by each team.

Consequences

Missed tests, delayed treatment, repeated investigations and avoidable patient harm.

Existing controls

  • A written handover sheet lists each patient's diagnosis, plan and pending tests.
  • Doctors give a verbal handover at the bedside for patients on the sickest list.

Control gaps

Handover content is not checked, and the handover sheet is not linked to the electronic record.

Additional controls

  • Prevent: Use one structured handover format for nurses and doctors and make the key fields mandatory in the record.
  • Detect: Audit a sample of handovers each month against a checklist of required items.
Likelihood 4 x impact 3 before; 2 x 3 after Owner: Senior registrar Target: Within 45 days Early warning: A handover audit that finds pending results or plans missing for more than one patient in a shift.
H04

Breach of patient privacy and records

Technology and data Before 12 After 4

Clinical notes or results are viewed by staff without a reason, printed or left on screens, or sent to the wrong person, which breaks confidentiality and trust.

Who or what is affected: Patients, families, staff and the hospital's information team

Causes

Broad access rights, shared workstations, and busy staff who print or copy records without thinking.

Consequences

Breach of confidence, complaint or regulator notification, and loss of public trust.

Existing controls

  • Staff sign a confidentiality agreement before access is given.
  • Screens lock after a short period of inactivity.

Control gaps

Access reports are not reviewed, and shared workstations are not always logged out.

Additional controls

  • Prevent: Limit record access by role and require a reason for opening records outside a care team.
  • Detect: Run monthly access reports to flag records viewed by staff with no link to their assigned patients.
  • Respond: Investigate each flagged access and apply the agreed disciplinary and reporting steps.
Likelihood 3 x impact 4 before; 2 x 2 after Owner: Information governance lead Target: Within 60 days Early warning: More than a set number of record views by one user with no link to assigned patients in a month.
H05

Hospital acquired infection and exposure

Safety Before 12 After 6

Patients or staff pick up infections such as a resistant organism or a blood borne virus through poor hand hygiene, unsafe sharps use or inadequate isolation of a patient.

Who or what is affected: Patients, nurses, doctors, visitors and cleaning staff

Causes

Heavy workload, limited side rooms, and sharps used in busy moments.

Consequences

Infection spread to other patients, staff sickness, and needlestick exposure requiring urgent treatment.

Existing controls

  • Hand hygiene is audited and alcohol gel is placed at each bed space.
  • Patients with known resistant organisms are placed in side rooms where possible.

Control gaps

Audit results are reviewed late and sharps bins are sometimes full at the bedside.

Additional controls

  • Prevent: Use single use sharps devices and safe disposal bins at the point of use, checked at each round.
  • Detect: Track infection rates and isolation compliance on the ward each month and report trends.
  • Recover: Follow a written post exposure procedure with occupational health review without delay.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Infection prevention and control nurse Target: Within 30 days Early warning: Hand hygiene audit scores falling below the agreed standard for two consecutive weeks.
H06

Staffing shortfall and unverified competence

People Before 12 After 6

The ward runs short of nurses or doctors, or agency and bank staff are rostered without checks on their skills, so care is delayed and tasks are done by people not trained for them.

Who or what is affected: Patients, permanent staff and agency staff

Causes

Sickness, vacancies, unpredictable admissions and reliance on agency cover.

Consequences

Missed observations, unsafe skill mix, staff burnout and rising error rates.

Existing controls

  • A safe staffing tool is used to set the roster each shift.
  • Agency staff receive a short induction before working alone.

Control gaps

Competence records for bank staff are held on paper and not checked against the roster.

Additional controls

  • Prevent: Verify licenses and competence records for every agency worker before the first shift.
  • Respond: Escalate to the duty manager when staffing falls below the safe minimum and pause nonessential admissions if needed.
Likelihood 4 x impact 3 before; 3 x 2 after Owner: Nurse manager for the ward Target: Within 45 days Early warning: A shift that runs below the safe staffing minimum or has an agency worker without a checked competence record.
H07

Equipment and information system failure

Technology and data Before 9 After 4

Monitors, infusion pumps or the electronic record fail or lose data, so observations are missed, orders are delayed and staff rely on manual workarounds.

Who or what is affected: Patients, clinical staff and the information support team

Causes

Ageing devices, shared equipment across bays, and network outages.

Consequences

Missed deterioration, delayed treatment, data loss and manual errors during downtime.

Existing controls

  • Devices are serviced on a set schedule and tagged with a service date.
  • The record is backed up each night and staff know the downtime forms.

Control gaps

Device checks are not logged consistently and downtime drills have not been run recently.

Additional controls

  • Detect: Check each device alarm and battery at the start of every shift and log any fault.
  • Recover: Test restoring the record from backup and rehearse the downtime procedure every six months.
Likelihood 3 x impact 3 before; 2 x 2 after Owner: Clinical engineering manager Target: Within 60 days Early warning: A device with an overdue service date or repeated alarms and faults within one week.
H08

Consent and documentation gaps

Legal and compliance Before 9 After 4

Consent for procedures or treatment is not recorded, or clinical notes are incomplete, late or unclear, so the patient's choices and the team's decisions cannot be shown or defended.

Who or what is affected: Patients, clinicians and the hospital's legal and governance teams

Causes

Time pressure, unfamiliar forms, and capacity assessments that are not written down.

Consequences

Challenge to treatment decisions, complaints, poor care continuity and legal exposure.

Existing controls

  • A consent form is required before any procedure on the ward.
  • Ward rounds are documented in the electronic record each day.

Control gaps

Audit is occasional and does not check whether consent was recorded before the procedure.

Additional controls

  • Prevent: Make consent and capacity fields mandatory before a procedure can be booked on the system.
  • Detect: Audit a sample of records each month for consent, capacity and decision notes.
  • Respond: Return incomplete records to the author with a deadline and report repeated gaps to the clinical lead.
Likelihood 3 x impact 3 before; 2 x 2 after Owner: Clinical governance lead Target: Within 60 days Early warning: A procedure logged without a consent record or a capacity note in the record.

Rating method and evaluation

Each risk is rated on two five-point scales. Likelihood runs from Rare to Almost certain, and impact runs from Minor to Catastrophic. Multiplying the two gives a score from 1 to 25, which falls into one of four bands: Low from 1 to 4, Medium from 5 to 9, High from 10 to 16 and Critical from 17 to 25. Inherent risk is the score before any controls, and residual risk is the score after the existing and added controls. Residual must never be higher than inherent, and where inherent is 10 or more the reduction must be shown. Harm to a patient is judged at its worst credible level, not its most common one, so a rare but severe event is not rated down. Critical needs immediate senior attention and a dated plan, High needs a named owner and action within 60 days, Medium needs routine controls and checks, and Low is accepted and watched. Scores are challenged by the ward team, by patients and families where appropriate, and by the clinical governance group. A risk is re-rated whenever its early warning indicator reaches the threshold or after a serious event. This scoring is a teaching guide for ordering work, and it does not replace clinical judgment or a formal site-specific assessment.

Likelihood, impact and rating bands

Likelihood

  • 5 Almost certain: Expected to happen in most circumstances.
  • 4 Likely: Will probably happen in many circumstances.
  • 3 Possible: Could happen at some time.
  • 2 Unlikely: Not expected, but it could happen.
  • 1 Rare: Only in exceptional circumstances.

Impact

  • 1 Insignificant: No lasting effect. Handled within routine work.
  • 2 Minor: Small effect that is quickly corrected.
  • 3 Moderate: Noticeable effect that needs managed effort to correct.
  • 4 Major: Serious effect on people, delivery or reputation.
  • 5 Catastrophic: Severe or lasting effect that threatens the whole activity.

Bands (likelihood x impact)

  • Low (1 to 4): Accept and monitor.
  • Medium (5 to 9): Manage with routine controls.
  • High (10 to 16): Senior attention and a treatment plan.
  • Critical (17 to 25): Act first. Do not proceed until reduced.

Monitoring, escalation and review

Review this assessment every 3 months, and sooner when an indicator below reaches its threshold.

Early-warning indicators and escalation thresholds
Indicator to watchEscalate when
Missed observation sets or scores that rise twice without a documented senior review.Escalate to the clinical lead for the ward at once, and to the medical director if the pattern continues for a week.
Medicines reconciliation not completed within 24 hours of admission.Escalate to the ward pharmacist lead when more than one patient in a week is affected, and to the clinical governance lead after two weeks.
Handover audit finding pending results or plans missing for any patient.Escalate to the senior registrar the same shift, and to the clinical lead if the finding repeats within a month.
Record views by a user with no link to an assigned patient in a month.Escalate to the information governance lead within two working days, and to the hospital privacy officer if the access is confirmed.
Shifts that fall below the safe staffing minimum or agency workers without a checked competence record.Escalate to the duty manager immediately, and to the chief nurse if the shift cannot be safely covered.

Contingency arrangements

If a serious event occurs, such as sudden deterioration with harm, a serious medication error or a confirmed privacy breach, the senior clinician on duty provides immediate care and calls the rapid response team. The ward manager secures records, stops the unsafe process and informs the clinical lead. Open disclosure is given to the patient and family by the treating team with support from the duty manager. The information governance lead assesses any breach and the notifications it requires. Staff are supported, and the event is reviewed with lessons shared across the hospital.

Prioritized action plan

  1. Publish a written escalation ladder for every early warning score band, owner clinical lead for the ward, within 30 days.
  2. Introduce one structured handover format and audit a sample each month, owner senior registrar, within 45 days.
  3. Complete medicines reconciliation within 24 hours of admission, owner ward pharmacist lead, within 30 days.
  4. Verify competence records for agency and bank staff before their first shift, owner nurse manager, within 45 days.
  5. Set mandatory consent and capacity fields and audit a sample of records, owner clinical governance lead, within 60 days.

Conclusion

Safe ward care depends on steady habits: early recognition of deterioration, structured handover, reconciled medicines, checked competence, protected records and complete consent notes. The highest scores sit with deterioration and medication harm, and each has actions that bring the residual score down. Treat the register as a living record, review it every three months, and seek qualified clinical and legal advice for any real decision about patient care or disclosure.

Assumptions and limitations

Assumptions

  • The ward follows a recognized early warning score and a written escalation policy set by the hospital.
  • Staff are licensed clinicians who have completed induction, and agency staff receive a local briefing before working alone.
  • Jurisdiction and health system are not specified, so legal duties are described in general terms only.

Limitations

  • The scores are examples for learning and do not describe any real ward or patient group.
  • Clinical practice, drug dosing and privacy law differ by country and change over time, so specialist review is needed.
  • This is educational content and does not replace a formal site-specific assessment or licensed clinical advice.

Related frameworks to study

  • Early warning scoring and escalation pathways
  • Structured clinical handover using a recognized format
  • Hierarchy of controls
  • Three lines model of risk ownership
  • Principles of informed consent and confidentiality

Healthcare Risk Assessment

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For Learning Reference Only: This assessment demonstrates how risk assessment principles are applied in a practical setting, providing a useful reference for learning and understanding. Actual assessments may be adapted to suit specific site conditions and circumstances.

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