11 - 10. Risk assessment

10. Risk assessment

© SPMM Course 10. Risk assessment Risk is the likelihood that harm will occur. Risk assessment is a process of scientific (statistical/clinical) calculation of likelihood of an adverse event; this includes specifying

1. What will happen?
2. When will this happen?
3. By whom will this happen?
4. How will this happen? Risk management is integral to assessment; Assessment is not carried out to label people and categorise into groups – it is a dynamic process and specific to the event of importance. Risk cannot be eliminated but only reduced. Problems with ‘predicting’ risk:  Low base rate: The events of interest are usually very rare. Hence the predictive value is generally low. Serious violence is rare amongst the severely mentally ill disordered, killing or maiming of others is measured in probabilities of less than 1% (Wallace 1998). This low base rate seriously compromises the predictive utility of risk assessment because of the false positive rate of even an exceptionally good risk assessment instrument.  Multifactorial: Risk is dependent on several factors, which tend to change over time.  Unknown interactions: Comprehensive risk evaluations are time-consuming; often the degree and nature of interaction among various factors is unknown. Risk factors for any untoward incident (suicide, crime or violence) can be categorized as static, stable and dynamic factors (Bouch & Marshall, 2003).  Static risk factors: These are fixed and historical: e.g. family history of suicide. They cannot be modified.  Stable risk factors: These are long term, enduring issues but are modifiable to some extent and not fixed: e.g. diagnosis of personality disorder.  Dynamic risk factors fluctuate markedly in both duration and intensity: the e.g. presence of acute anxiety symptoms or akathisia. A dynamic risk factor can act synergistically and multiply the effect of underlying static and stable risk factors if not addressed promptly. Certain dynamic factors may occur only in future (e.g. upon discharge, a patient may feel helpless). A comprehensive risk assessment should consider static, stable, dynamic and future risk factors and include them in devising risk management strategies.