risk assessment review

A complete guide to the risk assessment process

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Mark Zuckerberg, the founder of Facebook, once said, “The biggest risk is not taking any risk. In a world that's changing really quickly, the only strategy that is guaranteed to fail is not taking risks.”

While this advice isn't new, we think you’ll agree that there are some risks your company doesn’t want to take: Risks that put the health and well-being of your employees in danger.

These are risks that aren’t worth taking. But it’s not always clear what actions, policies, or procedures are high-risk. 

That’s where a risk assessment comes in.

With a risk assessment, companies can identify and prepare for potential risks in order to avoid catastrophic consequences down the road and keep their personnel safe.

What is risk assessment?

During the risk assessment process, employers review and evaluate their organizations to:

• Identify processes and situations that may cause harm, particularly to people (hazard identification).
• Determine how likely it is that each hazard will occur and how severe the consequences would be (risk analysis and evaluation).
• Decide what steps the organization can take to stop these hazards from occurring or to control the risk when the hazard can't be eliminated (risk control).

It’s important to note the difference between hazards and risks. A hazard is anything that can cause harm , including work accidents, emergency situations, toxic chemicals, employee conflicts, stress, and more. A risk, on the other hand, is the chance that a hazard will cause harm . As part of your risk assessment plan, you will first identify potential hazards and then calculate the risk or likelihood of those hazards occurring.

The goal of a risk assessment will vary across industries, but overall, the goal is to help organizations prepare for and combat risk. Other goals include:

• Providing an analysis of possible threats
• Preventing injuries or illnesses
• Meeting legal requirements
• Creating awareness about hazards and risk
• Creating an accurate inventory of available assets
• Justifying the costs of managing risks
• Determining the budget to remediate risks
• Understanding the return on investment

Businesses should perform a risk assessment before introducing new processes or activities, before introducing changes to existing processes or activities (such as changing machinery), or when the company identifies a new hazard.

The steps used in risk assessment form an integral part of your organization’s health and safety management plan and ensure that your organization is prepared to handle any risk.  

Preparing for your risk assessment 

Before you start the risk management process, you should determine the scope of the assessment, necessary resources, stakeholders involved, and laws and regulations that you’ll need to follow. 

Scope: Define the processes, activities, functions, and physical locations included within your risk assessment. The scope of your assessment impacts the time and resources you will need to complete it, so it’s important to clearly outline what is included (and what isn’t) to accurately plan and budget. 

Resources : What resources will you need to conduct the risk assessment? This includes the time, personnel, and financial resources required to develop, implement, and manage the risk assessment. 

Stakeholders: Who is involved in the risk assessment? In addition to senior leaders that need to be kept in the loop, you’ll also need to organize an assessment team. Designate who will fill key roles such as risk manager, assessment team leader, risk assessors, and any subject matter experts. 

Laws and regulations: Different industries will have specific regulations and legal requirements governing risk and work hazards. For instance, the Occupational Safety and Health Administration (OSHA) sets and enforces working condition standards for most private and public sectors. Plan your assessment with these regulations in mind so you can ensure your organization is compliant. 

5 steps in the risk assessment process

Once you've planned and allocated the necessary resources, you can begin the risk assessment process.

Proceed with these five steps.

1. Identify the hazards

The first step to creating your risk assessment is determining what hazards your employees and your business face, including:

• Natural disasters (flooding, tornadoes, hurricanes, earthquakes, fire, etc.)
• Biological hazards (pandemic diseases, foodborne illnesses, etc.)
• Workplace accidents (slips and trips, transportation accidents, structural failure, mechanical breakdowns, etc.)
• Intentional acts (labor strikes, demonstrations, bomb threats, robbery, arson, etc.)
• Technological hazards (lost Internet connection, power outage, etc.)
• Chemical hazards (asbestos, cleaning fluids, etc.)
• Mental hazards (excess workload, bullying, etc.)
• Interruptions in the supply chain

Take a look around your workplace and see what processes or activities could potentially harm your organization. Include all aspects of work, including remote workers and non-routine activities such as repair and maintenance. You should also look at accident/incident reports to determine what hazards have impacted your company in the past.

Use Lucidchart to break down tasks into potential hazards and assets at risk—try our free template below.

2. Determine who might be harmed and how

As you look around your organization, think about how your employees could be harmed by business activities or external factors. For every hazard that you identify in step one, think about who will be harmed should the hazard take place.

3. Evaluate the risks and take precautions

Now that you have gathered a list of potential hazards, you need to consider how likely it is that the hazard will occur and how severe the consequences will be if that hazard occurs. This evaluation will help you determine where you should reduce the level of risk and which hazards you should prioritize first.

Later in this article, you'll learn how you can create a risk assessment chart to help you through this process.

4. Record your findings

If you have more than five employees in your office, you are required by law to write down your risk assessment process. Your plan should include the hazards you’ve found, the people they affect, and how you plan to mitigate them. The record—or the risk assessment plan—should show that you:

• Conducted a proper check of your workspace
• Determined who would be affected
• Controlled and dealt with obvious hazards
• Initiated precautions to keep risks low
• Kept your staff involved in the process

5. Review your assessment and update if necessary

Your workplace is always changing, so the risks to your organization change as well. As new equipment, processes, and people are introduced, each brings the risk of a new hazard. Continually review and update your risk assessment process to stay on top of these new hazards.

How to create a risk assessment chart

Even though you need to be aware of the risks facing your organization, you shouldn’t try to fix all of them at once—risk mitigation can get expensive and can stretch your resources. Instead, prioritize risks to focus your time and effort on preventing the most important hazards. To help you prioritize your risks, create a risk assessment chart.

The risk assessment chart is based on the principle that a risk has two primary dimensions: probability and impact, each represented on one axis of the chart. You can use these two measures to plot risks on the chart, which allows you to determine priority and resource allocation.

Be prepared for anything

By applying the risk assessment steps mentioned above, you can manage any potential risk to your business. Get prepared with your risk assessment plan—take the time to look for the hazards facing your business and figure out how to manage them.

Now it's time to create your own risk management process, here are five steps to get you started.

Lucidchart, a cloud-based intelligent diagramming application, is a core component of Lucid Software's Visual Collaboration Suite. This intuitive, cloud-based solution empowers teams to collaborate in real-time to build flowcharts, mockups, UML diagrams, customer journey maps, and more. Lucidchart propels teams forward to build the future faster. Lucid is proud to serve top businesses around the world, including customers such as Google, GE, and NBC Universal, and 99% of the Fortune 500. Lucid partners with industry leaders, including Google, Atlassian, and Microsoft. Since its founding, Lucid has received numerous awards for its products, business, and workplace culture. For more information, visit lucidchart.com.

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The Essentials of Effective Project Risk Assessments

By Kate Eby | September 19, 2022

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Performing risk assessments is vital to a project’s success. We’ve gathered tips from experts on doing effective risk assessments and compiled a free, downloadable risk assessment starter kit. 

Included on this page, you’ll find details on the five primary elements of risk , a comprehensive step-by-step process for assessing risk , tips on creating a risk assessment report , and editable templates and checklists to help you perform your own risk assessments.

What Is a Project Risk Assessment?

A project risk assessment is a formal effort to identify and analyze risks that a project faces. First, teams identify all possible project risks. Next, they determine the likelihood and potential impact of each risk.

During a project risk assessment, teams analyze both positive and negative risks. Negative risks are events that can derail a project or significantly hurt its chances of success. Negative risks become more dangerous when teams haven’t identified them or created a plan to deal with them.

A project risk assessment also looks at positive risks. Also called opportunities, positive risks are events that stand to benefit the project or organization. Your project team should assess those risks so they can seize on opportunities when they arise.

Your team will want to perform a project risk assessment before the project begins. They should also continually monitor for risks and update the assessment throughout the life of the project.

Some experts use the term project risk analysis to describe a project risk assessment. However, a risk analysis typically refers to the more detailed analysis of a single risk within your broader risk assessment. For expert tips and information, see this comprehensive guide to performing a project risk analysis. 

Project risk assessments are an important part of project risk management. Learn more from experts about best practices in this article on project risk management . For even more tips and resources, see this guide to creating a project risk management plan .

How Do You Assess Risk in a Project?

Teams begin project risk assessments by brainstorming possible project risks. Avoid missing important risks by reviewing events from similar past projects. Finally, analyze each risk to understand its time frame, probability, factors, and impact.  

Your team should also gather input from stakeholders and others who might have thoughts on possible risks. 

In general terms, consider these five important elements when analyzing risks:

• Risk Event: Identify circumstances or events that might have an impact on your project. 
• Risk Time Frame: Determine when these events are most likely to happen. This might mean when they happen in the lifecycle of a project or during a sales season or calendar year. 
• Probability: Estimate the likelihood of an event happening. 
• Impact: Determine the impact on the project and your organization if the event happens. 
• Factors: Determine the events that might happen before a risk event or that might trigger the event.

Project Risk Assessment Tools

Project leaders can use various tools and methodologies to help measure risks. One option is a failure mode and effects analysis. Other options include a finite element analysis or a factor analysis and information risk.

These are some common risk assessment tools:

• Process Steps: Identify all steps in a process.
• Potential Problems: Identify what could go wrong with each step.
• Problem Sources: Identify the causes of the problem.
• Potential Consequences: Identify the consequences of the problem or failure.
• Solutions: Identify ways to prevent the problem from happening.
• Finite Element Analysis (FEA): This is a computerized method for simulating and analyzing the forces on a structure and the ways that a structure could break. The method can account for many, sometimes thousands, of elements. Computer analysis then determines how each of those elements works and how often the elements won’t work. The analysis for each element is then added together to determine all possible failures and the rate of failure for the entire product.
• Factor Analysis of Information Risk (FAIR): This framework helps teams analyze risks to information data or cybersecurity risk.

How to Conduct a Project Risk Assessment

The project manager and team members will want to continually perform risk assessments for a project. Doing good risk assessments involves a number of steps. These steps include identifying all possible risks and assessing the probability of each.

Most importantly, team members must fully explore and assess all possible risks, including risks that at first might not be obvious.

“The best thing that a risk assessment process can do for any project, over time, is to be a way of bringing unrecognized assumptions to light,” says Mike Wills , a certified mentor and coach and an assistant professor at Embry-Riddle Aeronautical University’s College of Business. “We carry so many assumptions without realizing how they constrain our thinking.”

Steps in a Project Risk Assessment

Experts recommend several important steps in an effective project risk assessment. These steps include identifying potential risks, assessing their possible impact, and formulating a plan to prevent or respond to those risks.

Here are 10 important steps in a project risk assessment:

Step 1: Identify Potential Risks

Bring your team together to identify all potential risks to your project. Here are some common ways to help identify risks, with tips from experts:

• Review Documents: Review all documents associated with the project.
• Consider Industry-Specific Risks: Use risk prompt lists for your industry. Risk prompt lists are broad categories of risks, such as environmental or legal, that can occur in a project.
• Revisit Previous Projects: Use checklists from similar projects your organization has done in the past. 

• “What I like to do for specific types of projects is put together a checklist, a taxonomy of old risks that you've identified in other projects from lessons learned,” says Wendy Romeu, President and CEO of Alluvionic . “Say you have a software development program. You would pull up your template that includes all the risks that you realized in other projects and go through that list of questions. Then you would ask: ‘Do these risks apply to our project?’ That's kind of a starting point.” “You do that with your core project team,” Romeu says, “and it gets their juices flowing.” Learn more about properly assessing lessons learned at the end of a project in this comprehensive guide to project management lessons learned .
• Consult Experts: Conduct interviews with experts within and, in some cases, outside your organization.
• Brainstorm: Brainstorm ideas with your team. “The best scenario, which doesn't usually happen, is the whole team comes together and identifies the risks,” says Romeu.
• Stick to Major Risks: Don’t try to identify an unrealistic or unwieldy number of risks. “You want to identify possible risks, but you want to keep the numbers manageable,” says Wills. “The more risks you identify, the longer you spend analyzing them. And the longer you’re in analysis, the fewer decisions you make.”
• Look for Positive Risks: Identify both positive risks and negative ones. It’s easy to forget that risks aren’t all negative. There can be unexpected positive events as well. Some people call these opportunities , but in a risk assessment, experts call them positive risks. 

• “A risk is a future event that has a likelihood of occurrence and an impact,” says Alan Zucker, founding principal of Project Management Essentials , who has more than two decades of experience managing projects in Fortune 100 companies. “Risks can both be opportunities — good things — and threats. Most people, when they think about risk assessment, they always think about the negatives. I really try to stress on people to think about the opportunities as well.” Opportunities, or positive risks, might include your team doing great work on a project and a client wanting the team to do more work. Positive risks might include a project moving forward more quickly than planned or costing less money than planned. You’ll want to know how to respond in those situations, Zucker says. Learn more about project risk identification and find more tips from experts in this guide to project risk identification .

Step 2: Determine the Probability of Each Risk

After your team has identified possible risks, you will want to determine the probability of each risk happening. Your team can make educated guesses using some of the same methods it used to identify those risks.

Determine the probability of each identified risk with these tactics:

• Brainstorm with your team.
• Interview experts.
• Review similar past projects.
• Review other projects in the same industry.

Step 3: Determine the Impact of Each Risk

Your team will then determine the impact of each risk should it occur. Would the risk stop the project entirely or stop the development of a product? Or would the risk occurring have a relatively minor impact?

Assessing impact is important because if it’s a positive risk, Romeu says, “You want to make sure you’re doing the things to make it happen. Whereas if it's a high risk and a negative situation, you want to do the things to make sure it doesn't happen.”

There are two ways to measure impact: qualitative and quantitative. “Are we going to do just a qualitative risk assessment, where we're talking about the likelihood and the probability or the urgency of that risk?” asks Zucker. “Or are we going to do a quantitative risk assessment, where we're putting a dollar figure or a time figure to those risks?”

Most often, a team will analyze and measure risk based on qualitative impact. The team will analyze risk based on a qualitative description of what could happen, such as a project being delayed or failing. The team may judge that impact as significant but won’t put a dollar figure on it.

A quantitative risk assessment, on the other hand, estimates the impact in numbers, often measured in dollars or profits lost, should a risk happen. “Typically, for most projects, we don’t do a quantitative risk assessment,” Zucker says. “It’s usually when we’re doing engineering projects  or big, federal projects. That’s where we're doing the quantitative.”

Step 4: Determine the Risk Score of Each Event

Once your team assesses possible risks, along with the risk probability and impact, it’s time to determine a risk score for each potential event. This score allows your organization to understand the risks that need the most attention.

Often, teams will use a simple risk matrix to determine that risk score. Your team will assign a score based on the probability of each risk event. It will then assign a second score based on the impact that event would have on the organization. Those two figures multiplied will give you each event or risk a risk score.

Zucker says he prefers to assign the numbers 1, 5, and 10 — for low, medium, and high — to both the likelihood of an event happening and its impact. In that scenario, an event with a low likelihood of happening (level of 1) and low impact (level of 1) would have a total risk score of 1 (1 multiplied by 1). An event with a high likelihood of happening (level of 10) and a large impact (level of 10) would have a total risk score of 100.

Zucker says he prefers using those numbers because a scale as small as one to three doesn't convey the importance of high-probability and high-impact risks. “A nine doesn't feel that bad,” he says. “But if it's 100, it's like, ‘Whoa, I really need to worry about that thing.’”

While these risk matrices use numbers, they are not really quantitative. Your teams are making qualitative judgments on events and assigning a rough score. In some cases, however, teams can determine a quantitative risk score.

Your team might determine, based on past projects or other information, that an event has a 10 percent chance of happening. For example, if that event will diminish your manufacturing plant’s production capacity by 50 percent for one month, your team might determine that it will cost your company $400,000. In that case, the risk would have a risk score of $40,000.

At the same time, another event might have a 40 percent chance of happening. Your team might determine the cost to the business would be $10,000. In that case, the risk score is $4,000.

“Just simple counts start to give you a quantifiable way of looking at risk,” says Wills. “A risk that is going to delay 10 percent of your production capacity is a different kind of risk than one that will delay 50 percent of it. Because you have a number, you can gather real operational data for a week or two and see how things support the argument. You can start to compare apples to apples, not apples to fish.”

Wills adds, “Humans, being very optimistic and terrible at predicting the future, will say, ‘Oh, I don't think it'll happen very often.’ Quantitative techniques help to get you away from this gambler fallacy kind of approach. They can make or break your argument to a stakeholder that says, ‘I've looked at this, and I can explain mechanically, count by the numbers like an accountant, what's going on and what might go wrong.’”

Step 5: Understand Your Risk Tolerance

As your team considers risks, it must understand the organization’s risk tolerance. Your team should know what kinds of risks that organizational leaders and stakeholders are willing to take to see a project through.

Understanding that tolerance will also help your team decide how and where to invest time and resources in order to prevent certain negative events.

Step 6: Decide How to Prioritize Risks

Once your team has determined the risk score for each risk, it will see which potential risks need the most attention. These are risks that are high impact and that your organization will want to work hard to prevent.

“You want to attack the ones that are high impact and high likelihood first,” says Romeu. 

“Some projects are just so vital to what you do and how you do it that you cannot tolerate the risk of derailment or major failure,” says Wills. “So you're willing to spend money, time, and effort to contain that risk. On other projects, you're taking a flier. You're willing to lose a little money, lose a little effort.”

“You have to decide, based on your project, based on your organization, the markets you're in, is that an ‘oh my gosh, it's gonna keep me up every night’ kind of strategic risk? Or is it one you can deal with?” he says.

Step 7: Develop Risk Response Strategies

Once your team has assessed all possible risks and ranked them by importance, you will want to dive deeper into risk response strategies. That plan should include ways to respond to both positive and negative risks.

These are the main strategies for responding to threats or negative risks:

• Mitigate: These are actions you will take to reduce the likelihood of a risk event happening or that will reduce the impact if it does happen. “For example, if you’re building a datacenter, we might have backup power generators to mitigate the likelihood or the impact of a power loss,” says Zucker. You can learn more, including more tips from experts, about project risk mitigation .
• Avoid: If a certain action, new product, or new service carries an unacceptably high risk, you might want to avoid it entirely. 
• Transfer: The most common way that organizations transfer risk is by buying insurance. A common example is fire insurance for a building. Another is cybersecurity insurance that would cover your company in the event of a data breach. An additional option is to transfer certain risks to other companies that can do the work and assume its risks for your company. “It could be if you didn't want to have the risk of running a datacenter anymore, you transfer that risk to Jeff Bezos (Amazon Web Services) or to Google or whoever,” Zucker says.

These are the main strategies for responding to opportunities or positive risks:

• Share: Your company might partner with another company to work together on achieving an opportunity, and then share in the benefits.
• Exploit: Your company and team work hard to make sure an event happens because it will benefit your company.
• Enhance: Your company works to improve the likelihood of something happening, with the understanding that it might not happen.

These are the main strategies for responding to both threats and opportunities, or negative and positive risks:

• Accept: Your company simply accepts that a risk might happen but continues on because the benefits of the action are significant. “You're not ignoring the risks, but you're saying, ‘I can't do anything practical about them,’” says Wills. “So they're there. But I'm not going to spend gray matter driving myself crazy thinking about them.”
• Escalate: This is when a project manager sees a risk as exceptionally high, impactful, and beyond their purview. The project manager should then escalate information about the risk to company leaders. They can then help decide what needs to happen. “Some project managers seem almost fearful about communicating risks to organization leaders,” Romeu says. “It drives me nuts. It's about communicating at the right level to the right people. At the executive level, it’s about communicating what risks are happening and what the impact of those risks are. If they happen, everybody knows what the plan is. And people aren't taken by surprise.”

Step 8: Monitor Your Risk Plans

Your team will want to understand how viable your organization’s risk plans are. That means you might want to monitor how they might work or how to test them.

A common example might be all-hands desktop exercises on a disaster plan. For example, how will a hospital respond to a power failure or earthquake? It’s like a fire drill, Zucker says. “Did we have a plan? Do people know what to do when the risk event occurs?”

Step 9: Perform Risk Assessments Continually

Your team will want to continually assess risks to the project. This step should happen throughout your project, from project planning to execution to closeout. 

Zucker explains that the biggest mistake teams tend to make with project risk assessment: “People think it's a one-and-done event. They say, ‘I’ve put together my risk register, we’ve filed it into the documents that we needed to file, and I'm not worrying about it.’ I think that is probably the most common issue: that people don't keep it up. They don't think about it.”

Not thinking about how risks change and evolve throughout a project means project leaders won’t be ready for something when it happens. That’s why doing continual risk assessment as a primary part of risk management is vital, says Wills.

“Risk management is a process that should start before you start doing that activity. As you have that second dream about doing that project, start thinking about risk management,” he says. “And when you have completely retired that thing — you've shut down the business, you've pensioned everybody off, you’re clipping your coupons and working on your backstroke — that's when you're done with risk management. It's just a living, breathing, ongoing thing.”

Experts say project managers must learn to develop a sense for always assessing and monitoring risk. “As a PM, you should, in every single meeting you have, listen for risks,” Romeu says. “A technical person might say, ‘Well, this is going to be difficult because of X or Y or Z.’ That's a risk. They don't understand that's a risk, but as a PM, you should be aware of that.”

Step 10: Identify Lessons Learned

After your project is finished, your team should come together to identify the lessons learned during the project. Create a lessons learned document for future use. Include information about project risks in the discussion and the final document.

By keeping track of risks in a lessons learned document, you allow future leaders of similar projects to learn from your successes and failures. As a result, they can better understand the risks that could affect their project.

“Those lessons learned should feed back into the system — back into that original risk checklist,” Romeu says. “So the next software development project knows to look at these risks that you found.”

How to Write a Project Risk Assessment Report

Teams will often track risks in an online document that is accessible to all team members and organization leaders. Sometimes, a project manager will also create a separate project risk assessment report for top leaders or stakeholders.

Here are some tips for creating that report:

• Find an Appropriate Template for Your Organization, Industry, and Project: You can find a number of templates that will help guide you in creating a risk assessment report. Find a project risk assessment report template in our project risk assessment starter kit.
• Consider Your Audience: As you create the report, remember your audience. For example, a report for a technical team will be more detailed than a report for the CEO of your company. Some more detailed reports for project team members might include a full list of risks, which would be 100 or more. “But don't show executives that list; they will lose their mind,” says Romeu.

Project Risk Assessment Starter Kit

Download Project Risk Assessment Starter Kit

This starter kit includes a checklist on assessing possible project risks, a risk register template, a template for a risk impact matrix, a quantitative risk impact matrix, a project risk assessment report template, and a project risk response table. The kit will help your team better understand how to assess and continually monitor risks to a project.

In this kit, you’ll find: 

• A risk assessment checklist PDF document and Microsoft Word to help you identify potential risks for your project. The checklist included in the starter kit is based on a document from Alluvionic Project Management Services.
• A project risk register template for Microsoft Excel to help you identify, analyze, and track project risks.
• A project risk impact assessment matrix for Microsoft Excel to assess the probability and impact of various risks.
• A quantitative project risk impact matrix for Microsoft Excel to quantify the probability and impact of various risks. 
• A project risk assessment report template for Microsoft Excel to help you communicate your risk assessment findings and risk mitigation plans to company leadership.
• A project risk response diagram PDF document and Microsoft Word to better understand how to respond to various positive and negative risks.

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How to Conduct a Risk Audit and a Risk Review

•  Minute Read

A life well-lived life involves looking backward as well as thinking forward. The same is true of projects.

In this article, we will look at how to conduct a risk management audit to evaluate the effectiveness of your risk management. We'll also talk about how to be more forward-thinking through risk reviews.

“Good Risk Management fosters vigilance in times of calm and instills discipline in times of crisis.” -Dr. Michael Ong

How to Conduct a Risk Management Audit

Who performs the risk management audits.

The project manager, the project manager and team, or a risk audit team may perform risk audits. What is the focus of the audit? It is a retrospective review where we ask "How did we do?"

• Review the effectiveness of the responses to risks
• Next, review the effectiveness of the risk owners
• Another, review the effectiveness of the risk processes

How Do Risk Audits Help?

Wonder if risk audits can really help you and your team. You bet!

And it doesn't have to be difficult or require lots of time.

The output of the risk audit is the lessons learned that enable the project manager and the team to increase the likelihood and impact of positive events and decrease the likelihood and impact of negative events.

The size of the risk audit team and the time invested should be commensurate with the size and complexity of the projects. I've completed small risk audits with me and a couple of team members in an hour or less.

Sounds great, but how does it really work?

Real World Audits

Tom was asked to manage a project to implement an insurance company claims customer service center that would house 100 employees. He decided to have a risk audit performed when the team had completed 40% of the project. Things were going fairly well, but Tom was concerned about an increasing number of issues, particularly with two risk owners.

Tom asked an internal risk audit group -- comprised of one company project manager, one IT employee, and one claims manager -- to conduct the audit. The team completed the audit in two weeks and discovered the following:

• To start with, one risk owner -- John Billings -- had been negligent in managing a significant risk for a critical path activity, resulting in an adverse impact to the schedule of two weeks. Why had Mr. Billings been negligent? He had lost two employees in the last two months, forcing him to pick up the slack.
• Next, there were two major risks where no responses had been taken and there were no contingency or fallback plans.
• Furthermore, the team missed an opportunity that could have saved the project $20,000.
• Finally, the risk evaluation process needed improvements. The scale being used for the qualitative risk analysis was broad and prone to bias.

The findings were shared with Tom and the project sponsor. The following changes were made:

• First, John Billings was replaced with another risk owner.
• Second, Tom met with the risk owners who had failed to respond to their risks, shared the audit findings, and asked that response plans be developed and executed.
• Third, Tom included specific exercises to identify opportunities going forward in the project.
• Lastly, Tom refined the qualitative risk evaluation scale.

“Risk is like fire: If controlled, it will help you; if uncontrolled, it will rise up and destroy you.” –Theodore Roosevelt

How to Conduct Risk Reviews

How can project managers make better decisions and get better results in the future? Try a risk review.

Remember, the audit team focuses on "How did we do?" Were the risk management processes effective? We are looking backward.

In contrast, risk reviews are prospective and forward-looking.  We ask,  "How will we do?" We modify our risk response plans and risk management processes to improve our chances in the future. 

Questions to Ask in Risk Reviews

Project managers and their teams periodically review their project risks for the following:

• What have we learned from our risk audits that we should apply going forward?
• Are there new risks?
• Has the probability and impact changed?
• Are individual risks merging to form a robust set of risks?
• Should we modify our responses, including contingency and fallback plans?
• Should we close irrelevant risks?
• Are the residual risks increasing or decreasing?

Check out my post 12 Questions For Monitoring Project Risks for more helpful questions.

Pick one of your worst project, where things have been crazy. Look backward with a risk audit and forward with a risk review. You will likely gain insights and perspective as you see things with fresh eyes. Best wishes!

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How to carry out a risk assessment

Review risk assessment regularly.

Information and guidance on reviewing any risk assessments and how frequently that should be done

​You must regularly review your risk assessments to make sure that they are still valid. It is recommended that you review them at least once a year. 

You should also review them before changes to the following take place:

It is important to review your risk assessment after an accident or near-miss. This can help prevent them from happening again.​

​Carry out a risk assessment

Once you are familiar with all the steps explained in this guide, you can carry out a risk assessment using our form.

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Understanding the Risk Assessment Process: A Comprehensive Guide

August 9, 2023

Risk assessment helps organizations identify potential threats, analyze their potential impact, evaluate their likelihood of occurrence, and ultimately make informed decisions to mitigate these risks .

This comprehensive guide aims to thoroughly understand the risk assessment process , covering the key steps and their significance.

The first step in the risk assessment process is risk identification, where potential risks are identified and documented. This involves a systematic review of the organization’s operations, processes, and external factors that could pose a threat.

Next comes risk analysis, which involves assessing the identified risks in terms of their likelihood and potential impact. This step requires a careful examination of available data and information to determine the severity of each risk and prioritize them accordingly.

Risk evaluation follows risk analysis, where the identified risks are evaluated based on predefined criteria such as legal requirements, financial impact, and reputational damage. This step helps decision-makers understand the significance of each risk and determine the appropriate risk response strategies.

Lastly, effective risk communication is crucial in ensuring all stakeholders know the identified risks, their potential impact, and the proposed risk mitigation strategies. This step involves clear and concise communication of the risk assessment findings to facilitate informed decision-making.

Organizations can effectively manage risks by thoroughly understanding the risk assessment process, which allows them to identify and address potential risks, ensuring the protection of their operations, reputation, and overall success.

In the risk assessment process, assessing the likelihood and severity of potential risks is crucial. This involves evaluating the probability of a risk occurring and its potential impact on the project or organization.

Once the likelihood and severity are determined, a matrix chart can be used to determine the risk level. This chart helps categorize risks into different priority levels, allowing for a more efficient allocation of resources and mitigation strategies.

After assessing the risk level, measures should be taken to reduce the identified risks. These measures can include implementing safety protocols, conducting training programs, or developing contingency plans.

It is essential to regularly reassess the risks to ensure that the mitigation measures are effective and if necessary, make adjustments accordingly.

Finally, the appropriate actions should be applied based on the updated risk assessment findings. This could involve implementing additional risk control measures, adjusting project timelines, or reallocating resources.

2. Assess Likelihood and Severity

When considering risk assessment , evaluating the probability and potential impact of an event is crucial. This step, known as assessing likelihood and severity, helps understand the potential consequences of the identified risks. The risk events can be In the form of categories of risks.

Likelihood of risk refers to the chances of a specific event occurring, while risk severity refers to the degree of harm or damage that could result from that event. Assessing both factors allows for a comprehensive understanding of the risk levels involved.

The risk assessment involves identifying potential hazards , assessing their likelihood and severity, and then prioritizing them based on their potential impact.

Organizations can use risk assessments to evaluate the probability and impact of risks, enabling them to identify and prioritize the most significant risks they face. This, in turn, helps them develop appropriate risk management strategies.

3. Use the Matrix Chart to Determine Risk Level

Utilizing the matrix chart enables organizations to effectively determine the level of risk involved by evaluating the likelihood and severity of potential events. This step is crucial in risk assessment , allowing organizations to prioritize and allocate resources accordingly.

The matrix chart, a risk matrix or risk assessment matrix, typically consists of a 2-column and 5-row table. The columns represent the likelihood of an event occurring, ranging from very low to very high.

The rows in the matrix represent the severity of the event’s impact, ranging from insignificant to catastrophic. Organizations can visually assess the overall risk level by placing potential events in the appropriate cells of the kinds of risk.

Examples include safety risks , environmental risks for effective risk management, corrective actions, and additional controls like power failures risks.

This comprehensive guide emphasizes the importance of using the matrix chart to enhance understanding and facilitate informed decision-making in risk management .

4. Take Measures to Reduce Risk

Organizations can implement preventive measures to mitigate potential risks and adopt strategies that minimize the likelihood and impact of adverse events. Reasonable steps taking into account the operating environment and business environment must be adopted.

One key aspect of risk management is hazard identification , which involves identifying potential risks and their characteristics. This can be done through various methods, such as conducting thorough inspections, analyzing historical data, and involving experts in the field.

Another important aspect is conducting quantitative risk assessments , which involve assessing the probability and severity of risks. This allows organizations to prioritize and allocate resources accordingly.

Effective risk communication ensures all stakeholders know potential risks and understand the control measures.

Integrating risk management strategies into the overall risk management process, organizations can effectively reduce the likelihood and impact of potential risks.

5. Reassess the Risk

Reevaluating the potential risks allows organizations to gain a deeper insight into their vulnerabilities and instill a sense of urgency in implementing effective risk reduction strategies.

Through a systematic reassessment process, organizations can evaluate any potential changes in their environment or operations that could potentially influence the level of risk. This entails reviewing the original risk assessment , gathering updated information, and analyzing the data to ascertain if any modifications are necessary for the risk management plan.

Reassessing the risk also provides an opportunity to evaluate the effectiveness of existing risk mitigation measures and identify any gaps or areas for improvement. This iterative approach ensures that organizations have an ongoing understanding of their risks and can adapt their risk management strategies accordingly.

6. Apply the Appropriate Actions

Implementing the appropriate actions is crucial in effectively managing risks and minimizing their potential impact on an organization. As outlined in this comprehensive guide, the risk assessment process provides a systematic approach to identifying, analyzing, and evaluating risks.

Once risks have been assessed and their likelihood and severity determined, taking the necessary actions to mitigate or eliminate them is essential. This can be achieved by following a risk assessment matrix, which assigns risk scores to each identified risk based on its likelihood and severity.

The risk assessment matrix is a useful tool for prioritizing risks and allocating resources. Conducting qualitative risk assessments and utilizing risk matrices allows organizations to make informed decisions about which risks to address first and how to effectively manage them, ensuring the overall safety and success of the organization.

Risk Identification

Risk identification involves systematically identifying potential risks that may impact an organization’s objectives, ensuring a proactive approach to mitigating and managing these risks.

Risk identification is a crucial step in the risk assessment process that helps organizations understand the potential threats they face and develop strategies to address them.

Identifying risks allows organizations to allocate their resources and efforts more effectively to address areas of concern.

This process thoroughly analyzes and examines factors such as internal and external environments, industry trends, and historical data.

Identifying risks requires a comprehensive understanding of the organization’s operations, goals, and potential vulnerabilities.

Risk Analysis

Risk analysis is a crucial step in the risk management process as it involves evaluating and examining potential risks and their potential impact on an organization’s objectives. It aims to identify the likelihood and severity of risks to prioritize them for mitigation strategies.

Various risk analysis methods, such as quantitative , qualitative, and semi-quantitative, can be employed. These methods allow organizations to assess risks based on their impact on safety, financials, reputation, and other critical factors.

Organizations commonly utilize a risk assessment template to streamline the risk analysis, facilitating the documentation and organization of identified risks and their potential impacts.

Through conducting a thorough risk analysis, organizations can gain a deeper understanding of the required types of risk assessments and develop strategies for professional risk management.

Risk Evaluation

Risk Analysis is an essential step in the risk assessment process, as it involves identifying and analyzing potential risks to determine their likelihood and potential impact. However, the process does not end there.

The next crucial step is Risk Evaluation. This section of the comprehensive guide focuses on evaluating the identified risks to determine their significance and prioritize them for further action.

Risk evaluation involves considering factors such as the severity of the potential consequences, the likelihood of the risk occurring, and the effectiveness of existing controls.

Two nested bullet point lists can provide a clear understanding of this process. The first list could outline the factors considered during risk evaluation, including consequence severity, likelihood, and control effectiveness.

The second list could provide examples of how these factors are assessed and weighted in the evaluation process, ensuring contextual relevance to the article section.

Risk Communication

Effective communication of risks is essential in ensuring that relevant stakeholders are well-informed and can make informed decisions based on accurate and reliable information.

Risk communication is crucial in conveying the potential risks associated with a particular situation or activity in the context of risk assessment .

It involves disseminating information about the identified risks , their likelihood, and potential consequences to individuals or groups who may be affected.

Effective risk communication requires clear and concise messaging tailored to the target audience’s understanding and familiarity with the subject matter.

It should also consider the use of appropriate channels and mediums for communication, such as written reports, presentations, or interactive workshops.

Effective risk communication involves providing relevant information and engaging stakeholders in the risk assessment , which aids in a comprehensive understanding of the risks and promotes informed decision-making.

Frequently Asked Questions

What are the common challenges faced during the risk identification process.

Common challenges during risk identification include lack of expertise, insufficient data, biased perception, and inadequate communication. These challenges hinder the accurate and comprehensive identification of risks, affecting the effectiveness of risk assessment and management.

How can organizations ensure that all potential risks are accurately assessed during the risk analysis?

Organizations can ensure an accurate assessment of potential risks during the risk analysis phase by implementing a systematic approach. This includes conducting comprehensive research, utilizing relevant data and expert opinions, and employing effective risk assessment tools and techniques.

What are the key factors to consider when evaluating the severity and likelihood of identified risks?

When evaluating the severity and likelihood of identified risks, key factors include the potential impact on the organization, the probability of the risk occurring, and any existing controls or mitigation measures.

How can risk evaluation results be effectively communicated to stakeholders and decision-makers?

Risk evaluation results can be effectively communicated to stakeholders and decision-makers through clear and concise reporting, using appropriate visual aids and language, and ensuring that the information is tailored to the specific needs and interests of the audience.

Are there any specific legal or regulatory requirements that organizations need to consider during the risk assessment process?

Organizations must consider specific legal and regulatory requirements during risk assessment . These requirements vary depending on the industry and jurisdiction, and failure to comply can lead to legal consequences and reputational damage.

Risk assessment is a crucial aspect of any organization’s risk management strategy. This comprehensive guide has provided a detailed overview of the different stages involved in this process.

Each step is vital in helping organizations understand and mitigate potential risks, from risk identification to risk analysis, evaluation, and communication.

Organizations can make informed decisions, effectively prioritize resources, and minimize the impact of risks on their operations by following a systematic approach.

A well-executed risk assessment process is important for ensuring an organization’s long-term success and sustainability.

Chris Ekai is a Risk Management expert with over 10 years of experience in the field. He has a Master’s(MSc) degree in Risk Management from University of Portsmouth and is a CPA and Finance professional. He currently works as a Content Manager at Risk Publishing, writing about Enterprise Risk Management, Business Continuity Management and Project Management.

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How to review a risk assessment

• February 8, 2022

Risk assessments are crucial to any business. They not only protect and prevent accidents, but are a legal requirement and an important step in ensuring a safe and healthy work environment. With that in mind, we explore how to review a risk assessment to help you focus on the risks which really matter in your workplace – the ones with the potential to cause real harm.  Risk assessment is a term used to describe the overall process or method where you:

• Identify hazards and risk factors that have the potential to cause harm (hazard identification).
• Analyse and evaluate the risk associated with that hazard (risk analysis, and risk evaluation).
• Determine appropriate ways to eliminate the hazard, or control the risk when the hazard cannot be eliminated (risk control).

A risk assessment is a thorough look at your workplace to identify those things, situations, processes, etc, that may cause harm, particularly to people. After identification is made, you analyse and evaluate how likely and severe the risk is. When this determination is made, you can next, decide what measures should be in place to effectively eliminate or control the harm from happening.

Legally, businesses are required to review risk assessments regularly. Under the HSE’s guidance, most businesses review them once a year, but it is also essential to be sure that any changes in the workplace have not introduced new hazards or changed hazards that were once ranked as lower priority to a higher priority. Reviewing your assessments on a regular basis is imperative to make sure your control methods are still effective.

Response for change

In a ever changing work environment, you should always consider revising your risk assessments if any of the following changes are made to your business operations: Accidents  Risk assessments must always be reviewed after an accident, incident or near miss, even if the assessment was recently reviewed. Accident and near-miss investigations are an opportunity to identify where weaknesses are so that you can re-assess the task and fill any gaps in your safety management. New equipment  Risk assessments need to be reviewed in light of any new equipment or procedure adjustments so that hazards can be identified and control measures implemented. Change of location/premises  Every work place is unique and although the actual work may be the same, the location may not be. A review will need to be conducted for a change of location or a one off working away from site. New staff  An increase or decrease in staff will require a review, as will any new job roles/descriptions or change of responsibility to existing staff. Legislation  Health and safety legislation is not static, particularly as new techniques, technology and work practices evolve. Regulations are constantly being reviewed, consulted on, and updated-your risk assessment reviews should reflect this. Documentation  Make a record of significant findings (this is a legal requirement if you have five or more employees) – the hazards, how people might be harmed by them and the control measures in place to reduce the risks. There is no legal time frame for when you should review your risk assessment. It is at your discretion to decide when a review is deemed necessary, but the risk assessment is a working document and, as your business experiences change, this information should be recorded and updated. For further information on how to review a risk assessment, please contact us here .

• Thought Leadership

ISO 31000: Monitoring and reviewing risk

The final stage of a successful risk management strategy that follows the ISO 31000 framework is monitoring and reviewing risk criteria, analysis, treatment, and the framework itself.

A comprehensive risk strategy involves continuous evaluation as the organisation evolves. It could be that reviews are performed annually, monthly, or weekly – it’s up to the leadership to determine the review and reporting requirements of the accountable individuals involved in delivering and monitoring risk processes.

In the final part of our blog series on ISO 31000, we look at clauses 6.6 and 6.7 and how to monitor and review the risks you have identified within your organisation.

Clause 6.6: Monitor and review the risk

As with all Standards within the higher Annex SL framework, the concept of Plan, Do, Check, Act applies to the risk management strategy an organisation creates under ISO 31000. An integral part of ensuring continuous quality and improvement in process, efficiency, and output is to monitor strategic goals and performance on a regular basis.

When a risk has changed, for example, an external factor such as the exchange rate has impacted upon trade, the risk treatment needs review. However, the whole risk strategy needs to be considered as a constantly evolving element as the objectives of an organisation change over time.

A review process should include all stakeholders, internal and external, to ensure a holistic input into the ongoing shaping of the risk management processes.

Clause 6.7: Recording and Reporting

Once you monitor and review the risk, the risk management process needs to be recorded and reported to:

• Ascertain the organisation’s stance on risk culture, appetite, and tolerance
• Communicate effectively to all stakeholders at key stages
• Deliver clear data on the effectiveness of risk treatment plans
• Improve engagement with stakeholders and draw on feedback
• Provide valuable information for decision making across the organisation

Reporting timeframes and performance metrics are to be determined at an early stage of the strategy development, to manage expectations of stakeholders and ensure timely and appropriate information gathering.

Reports should consider information such as the audience type, data sensitivity, and how the data relates to overall objectives and goals of the organisation.

That’s it! You’ve come to the end of your ISO 31000 Toolkit.

Now that you understand the importance of monitoring and reviewing risk, find out how one of our customers use our risk management software to manage data. 

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Ilo is a specialized agency of the united nations, a 5 step guide for employers, workers and their representatives on conducting workplace risk assessments.

This guide aims to help employers, workers and their representatives assess safety and health risks in the workplace.

5th August, 2021

How Often Do You Need To Review A Risk Assessment?

You might realise you need to review your risk assessments from time to time, and many people tend to go with an annual review. But there are times when risk assessments might need to reviewed sooner. Let's look at when, why, and how often you need to update your risk assessments.

Step 5 of the 5 steps to risk assessment is to 'review your assessment and update if necessary' . Sounds simple enough. But when, and how often, should you review your risk assessments?

If you are not already familiar with the 5 steps to risk assessments, check out our blog post - What Are The 5 Steps To Risk Assessment?

You might think about reviewing your risk assessments once a year, but what if things change in the meantime? You might think you can review it if the regulations change, but risks assessments are about reducing risks, not just legal limits. You might wonder if you can just plan to review it if there are problems, but what if problems don't get reported?

In this post, we will look at how often you need to review a risk assessment and the reasons for reviewing your risk assessment. Including:

• Annual reviews
• Changes in legislation
• Significant changes in the task
• Improvements you have made
• Problems arising from the task
• Accidents or near misses

Annual Reviews

You probably realise you need to review your risk assessments from time to time. And many businesses tend to go with an annual review of all of their health and safety documentation. And that's a good place to start.

If you're not reviewing at least annually, then it won't be long before clients or other people reviewing your health and safety documents (for example, health and safety accreditation schemes) send them back asking for up to date documents.

For example, CHAS require documents submitted for assessment to be within the last year.

Support this with examples of risk assessments and method statements or safe systems of work arising from those assessments completed in the past 12 months. CHAS Guidance Notes (April 2017)

But annual reviews alone might not always be enough. There are a few situations where you may need to bring your review forward to see if you need to make any updates sooner.

Legislation Changes

Health and safety legislation is not static, particularly as new techniques, technology and work practices evolve. Regulations are constantly being reviewed, consulted on, and updated.

Changes in health and safety law happen twice a year, roughly every six months:

• 6 April (the start of the tax year)

Don't panic. Not every regulation changes every year. That would be a nightmare to keep on top of - but changes do happen.

For example, recent health and safety regulation changes include the Ionising Radiations Regulations 2017, Explosives Regulations 2014 (Amendment) Regulations 2016 and Construction (Design and Management) Regulations 2015.

Recently the HSE consulted on future changes to other areas, including the radiation code of practice and workplace exposure limits.

If your risk assessment refers to a specific health and safety regulation or complies with one that changes on one of those dates, you should review it. Your review will check if it still complies with any changes made to the regulation, and you can update the risk assessment if you find you need to.

So you should be reviewing your risk assessments at least every year and when regulations change. But did you know there are occasions when you might need to review your risk assessments sooner than 12 months?

Your review could happen because of:

Most work activities evolve and change over time. You find better ways of doing things, innovate, introduce new tools and equipment, streamline the process, and (hopefully) make it safer.

But those new procedures, equipment and substances you bring in could introduce new hazards. They might introduce risks as well as removing some that were there before.

When changes happen, you should take another look at your risk assessment and see if it is still valid, updating it if required.

Improvements

When you first carry out your risk assessment, you might record further action measures needed and put an action plan together to carry out these improvements. For example, you could have decided to install a new conveyor belt to reduce manual handling. Or maybe you decided to get a new extraction or ventilation system to reduce exposure levels.

But not all improvements can happen right away. You have to plan for budgets or timeframes to get the work carried out. So later, when these control measures get introduced, the risk level will have changed (for the better). You can review and update your risk assessment again to reflect the improvements you made.

Once a risk assessment has been completed and put into action, the people doing the work might spot a problem you missed during the risk assessment process. Maybe a control measure or a procedure that isn't quite right. Perhaps a guard isn't compatible with a material you are using, or an item keeps getting jammed.

If problems come to light, it's an opportunity to put things right. You should review the activity and update your risk assessment where control measures need to be changed or where further improvements are necessary.

If any problems mentioned above don't get picked up quickly enough, then you'll likely end up here. Accidents and near misses can happen, and while you need to do everything you can to prevent them, you can also learn from them. And if you act quickly enough (e.g. when a near-miss happens), you can stop people from getting hurt.

Maybe you are getting quite a few near-miss reports for a particular task or activity. These near-misses are a clear indication that the risk assessment needs reviewing. If you can work out how you can prevent near misses, you can stop future accidents before they happen.

Accident and near-miss investigations are an opportunity to identify where weaknesses are so that you can re-assess the task and fill any gaps in your safety management.

If you need help creating your risk assessments, you can use the free blank risk assessment template or browse our library of risk assessment templates .

This article was written by Emma at HASpod . Emma has over 10 years experience in health and safety and BSc (Hons) Construction Management. She is NEBOSH qualified and Tech IOSH.

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How Often Should Risk Assessments Be Carried Out, and When Should Risk Controls Be Reviewed?

Risk assessments are important for protecting people from harm and ill-health. When carried out correctly, they can save lives. They’re also a legal requirement for most businesses, and they play a vital role in risk management strategies. But how often should risk assessments be reviewed?

Risk assessments are only effective and relevant if they’re kept up to date. Chances are, your workplace and business operations are constantly changing or being updated. Any small changes to your workplace can affect the hazards that pose health and safety risks to workers, site visitors and members of the public. Workplace changes can include new staff being onboarded, equipment being replaced, repaired or upgraded and the adjustment of procedures.

For hazards to be identified, and for risks to be mitigated quickly and successfully, risk assessments need to be updated and reviewed regularly. In the five steps to risk assessments outlined by the Health and Safety Executive, reviewing assessments is the fifth and final step, and it’s one that mustn’t be forgotten.

If you’re new to reviewing workplace risks and implementing control measures, you might be wondering how often risk assessments should be carried out, and when risk controls should be reviewed. So here’s what you need to know.

Set a Timeframe to Monitor and Review Risk Assessments

Legally, businesses are required to review risk assessments regularly. Under the HSE’s guidance, most businesses review them once a year. However, the exact time frame for reviewing assessments is for you to decide. You’ll need to take into account how regularly your business operations change, and the risk factor of business activities.

Risk assessments for higher risk activities might need to be reviewed more regularly, and control measures will need to be continuously monitored to ensure people are kept as safe as possible at all times. For example, dangerous construction sites will require more regular risk assessment reviews than low-risk workplaces such as offices.

For most businesses though, reviewing hazards, risks and control measures once a year is sufficient to achieve compliance, create a safe workplace and reduce the risks involved in business operations. However, there may be times when assessments need to be reviewed and updated ahead of schedule — such as whenever any major changes are made to the work environment or procedures.

Be Prepared to Review Risk Assessments in Response to Change

Whenever major changes are made in your workplace or procedures are adjusted, the hazards associated with work activities will inevitably change too. In addition to reviewing and updating risk assessments once a year — or however regularly you have decided to revisit them — you should also be prepared to review your assessments in response to changes.

You should consider revising your risk assessments if any of the following changes are made to your business operations:

• Change of Workplace If your business moves to a new location, if work is being carried out at a different site than usual, or if you expand and operate in multiple locations, risk assessments will need to be carried out for every workplace. Every work environment is unique, so existing risk assessments can’t be applied to other locations.
• New Equipment or Procedures Different procedures and pieces of equipment come with different hazards and risks. There may be risks relating to fire, electrical safety or personal injuries. Risk assessments need to be reviewed in light of any new equipment or procedure adjustments so that hazards can be identified and control measures implemented.
• Accidents, Injuries or near Misses You should be keeping a log of all accidents or injuries that occur in the workplace or as a result of work activities. This record can be a useful risk management tool. Whenever an incident occurs, review your risk assessment to see if anything could have been done differently to prevent it. If there’s a pattern of injuries or work-related ill-health, risk assessments need to be reviewed thoroughly to identify any possible causes and implement control measures.
• Changes to Your Workforce If your workforce increases or decreases, risk assessments may need to be adjusted accordingly. Similarly, if new roles are introduced into your workforce, risk assessments will need to be updated to include any role-specific hazards or responsibilities.

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Risk assessment

Evidence review B

NICE Guideline, No. 216

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This evidence report contains information on 2 reviews relating to preventing an escalation of need, the first being an effectiveness review and the second, a qualitative review.

• What is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs?
• Based on the views and experiences of everyone involved, what works well and what could be improved about social work risk assessments with adults with complex needs?
• Risk Assessment

Review questions

Introduction.

Risk assessment is a required core competency for social workers. The British Association of Social Workers (BASW) Professional Capabilities Framework states that experienced social workers must be competent to “anticipate, assess and manage risk, including in complex cases, and support others to develop risk management skills”. 1 Social Work England professional standards state that “Using an evidence-informed approach to make impartial decisions is an integral part of social work practice”. 2 Reviewing the quantitative and qualitative evidence regarding social work approaches to risk assessment was therefore identified as a topic of key relevance for this guideline.

Summary of the protocol

See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of the effectiveness review question.

See Table 2 for a summary of the Population and Phenomenon of interest for the qualitative review question.

Summary of the protocol (PICO table) – effectiveness question.

Summary of the protocol (population and phenomenon of interest) – qualitative question.

For further details see the review protocol in appendix A .

Methods and process

This was designed as a mixed-methods review using parallel synthesis. However, no quantitative data were located so there was no integration by the committee of the two types of evidence.

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual . Methods specific to this review question are described in the review protocol in appendix A and the methods document (supplementary document 1).

Declarations of interest were recorded according to NICE’s conflicts of interest policy .

Effectiveness evidence

Included studies.

A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.

See the literature search strategy in Appendix B and study selection flow chart in Appendix C .

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in Appendix J .

Summary of included studies

No studies were identified which were applicable to this review question (and so there are no evidence tables in Appendix D ). No meta-analysis was conducted for this review (and so there are no forest plots in Appendix E ).

Qualitative evidence

A systematic review of the literature was conducted using a combined search for all qualitative questions. Four studies were included in this review ( Nolan 2012 , O’Hare 2013 , Stevenson 2019 and Taylor 2013 ).

The included studies provided data on people’s views and experiences of social work risk assessments and risk management ( Nolan 2012 , O’Hare 2013 , Stevenson 2019 and Taylor 2013 ).

Data collection methods included face-to-face interviews, questionnaires and observation of project group discussions, and a survey using vignettes and open questions.

Study populations included adults living with mild to moderate dementia or adults living with disability; social work students or experienced social workers supporting people with mental health problems or people who self-neglect.

The included studies are summarised in Table 3 .

Studies not included in this qualitative review are listed, and reasons for their exclusion are provided in Appendix J .

Summaries of the studies that were included in the qualitative review are presented in Table 3 .

Summary of included studies.

See the full evidence tables in appendix D .

Sharing responsibility and decision making

Facilitating open discussions

Understanding risk from different perspectives

Contextual risk assessment

Helping to balance risk assessment and autonomy

Organisational support for risk assessment

Excluding people from risk assessment discussions

Definition and concept of risk

Resource pressures

Knowledge and training

Staff safety

Risk as a complex concept

Risk choices and adaptive strategies

The theme maps ( Figure 1 and Figure 2 ) illustrate these overarching themes, their related themes and sub-themes. Overarching themes are shown below in orange, related themes in blue and sub-themes in green.

theme map – what works well.

theme map – what could be improved.

Summary of the evidence

No studies were identified which were applicable to this review question (and so there are no GRADE tables in Appendix F ). No meta-analysis was conducted for this review (and so there are no forest plots in Appendix E ).

The evidence generated 6 central themes about the views and experiences of people with complex needs and practitioners involved in social work risk assessments. There was no evidence about relevant views and experiences of families and carers of people with complex needs.

All 4 qualitative studies provided evidence relating to ‘what works well’ in social work risk assessments. Relevant themes generated from the data included promoting good communication between relevant service providers and people at risk and assessing risk in the context of people’s broader lives. Benefits were also highlighted in relation to undertaking comprehensive assessments to identify the availability of support and services to promote risk management.

All 4 qualitative studies provided evidence relating to ‘what could be improved’ about social work risk assessments. Themes generated from the data related to issues including the willingness of people to engage with care, a lack of availability of risk assessment tools, and also other challenges and dilemmas faced by professionals.

See Appendix F for full GRADE-CERQual tables.

Economic evidence

A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.

A single economic search was undertaken for all topics included in the scope of this guideline. See supplement 2 for details.

A single economic search was undertaken for all topics included in the scope of this guideline. See supplement 2 for further information.

Summary of studies included in the economic evidence review

Economic model.

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.

The committee’s discussion and interpretation of the evidence

The outcomes that matter most.

Social work risk assessment involves balancing the potential benefits and the potential harms of risk-taking and of acting to manage risks. The committee therefore selected outcomes for the quantitative review which related both to potential benefits of social work risk assessment: service user and carer subjective quality of life; and outcomes relating to potential harms: mortality, adverse events resulting in emergency treatment or admission to hospital, harm to others, safeguarding incidents and care home admissions. Service user-focused outcomes were prioritised as critical outcomes: quality of life, mortality and adverse events requiring an immediate service response (emergency treatment or hospital admission).

To address the issue of what works well and what could be improved about risk assessment, the second part of the review was designed to include qualitative data and as a result the committee could not specify in advance the data that would be discovered. Instead, they agreed, by consensus, on the following main themes to guide the review, although the list was not exhaustive and the committee were aware that additional themes may be identified.

• Satisfaction with the process of accessing a social work risk assessment.
• Involvement of all relevant people.
• Relationship between risk assessment and other assessments.
• Satisfaction among service users.
• Subjective perception of risk.
• Assumptions about risk.
• Role/influence of culture and other equality issues.
• Perceived appropriateness of risk assessment (for example, usefulness, appropriateness, timeliness).
• Positive and negative aspects of risk assessment.
• Carers’ satisfaction with social work risk assessment.
• Practitioner satisfaction with social work risk assessment.

These themes were chosen as they cover aspects of what works and does not work well from the perspective of everyone involved. Questions focused on service users’ and other stakeholders’ experience of and satisfaction with social work risk assessment, for which qualitative research can provide rich evidence. The committee sought all available evidence about how assumptions and subjective perceptions of risk may influence social work risk assessment, and how culture and other equality issues may affect the process of assessment, because they recognised the importance of identifying and understanding potential sources of bias in the assessment process. The committee sought available evidence about risk assessment in the context of other assessments (such as needs assessments) because they recognise the need to balance risks of harm against service users’ needs and wishes in planning care and service response.

The quality of the evidence

There was no evidence identified for the effectiveness review question.

The qualitative evidence was assessed using GRADE-CERQual methodology and the overall confidence in the findings ranged from very low to moderate. The review findings were generally downgraded because of methodological limitations of the included studies, including, for example, limited information on the rigour of data analysis. The evidence was also downgraded due to the relevance of the findings because the study context in some instances was slightly different to the review protocol. Finally, some data were downgraded for adequacy because together, the studies did not offer rich data. The review findings were not downgraded for coherence because the evidence was not generally considered ambiguous or contradictory.

See appendix F for full GRADE-CERQual tables with quality ratings of all review findings.

Benefits and harms

Principles of social work for adults with complex needs – for social workers.

The committee used the evidence from this review to support the recommendation that social workers should discuss with a person how their experiences may impact their care needs, which had originally been made on the basis of evidence (C2.3.2 Relationships; low quality) from report C Case Management. The committee discussed the evidence from this review (B2.3.2 Risk choices and adaptive strategies; moderate quality) that highlighted some factors that increase risk such as homelessness, poverty and stigma. The committee agreed that the evidence supported the recommendation and would allow social workers to identify whether people were at a higher risk depending on any life circumstance or experience. They agreed that by identifying these factors they would be able to provide person-centred care specific to a person’s needs.

Principles of social work for adults with complex needs – for organisations

The committee discussed the evidence (B2.4.2 Knowledge & training; low quality; B2.4.3: Staff safety; very low quality) that suggested that a lack of knowledge on specific risk education and policies, could lead to further risk to the person. The committee agreed that although the evidence was of very low and low quality, it was important to address continuous professional development in a recommendation. The committee expanded on the evidence and made a recommendation that in all areas of social work for adults with complex needs, organisations should provide legal literacy training to social workers. They agreed this would benefit people using services as social workers would be able to support them with appropriate and specific care and knowledge.

Needs assessment – recording and reviewing the assessment

The committee used the evidence (B1.1.1 Sharing responsibility and decision-making; low) which suggested there could be dilemmas between professionals working in multi-disciplinary teams on balancing different perspectives related to risk. They also discussed the evidence (B2.2.1 Definition and concept of risk; moderate) that suggested these differences could also exist between professionals and people undergoing a risk assessment. Based on their experience in practice, differences in opinion can also create dilemmas when undergoing a needs assessment, as various different professionals can be involved in the process. The committee agreed it was important to address these issues with a recommendation relevant to a needs assessment, as it could create problems regarding access to care if professionals did not agree on factors such as meeting eligibility criteria. The committee acknowledged that they would not be able to resolve differing opinions, but agreed that by recommending that differences are formally recorded in case notes, they would be maintaining transparency. This would allow for a documented process that could be referred to if any issues arose.

Risk assessment – planning the assessment

The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence relating to the effectiveness of different approaches to a social work risk assessment, and the quality of the included qualitative evidence. However, they agreed that they would use the qualitative evidence, supported by their own experiential knowledge and relevant legislation (see the ‘ Other factors the committee took into account ’ section), to make recommendations about the principles of conducting social work risk assessment.

The committee discussed the evidence around what works well in approaches to risk assessment. In particular, they discussed evidence (B1.1.1 Sharing responsibility and decision-making; low quality; B1.3.1 Contextual risk assessment; moderate quality) that highlighted the importance of assessing risk in the context of people’s lives in order to better understand their specific risk factors. The committee agreed with the evidence and decided to make a recommendation to support a holistic approach to assessing risks. The committee agreed this recommendations would facilitate person-centred care and enable the identification of risks in all aspects of a person’s life. In this way, the social worker would be able to personalise care. The committee discussed some of the evidence around what could be improved (B2.1.1 Excluding people from risk discussions; low quality) which suggested that excluding the person at risk from discussions, and only involving professionals or their family, could lead to the person feeling disempowered. The committee agreed that it was important to highlight with a recommendation, that a person’s views regarding the involvement of family, carers or other people should be formally recorded. In addition to maintaining transparency, the committee agreed that this recommendation would strengthen a person-centred approach to risk assessment, and ensure that decision-making always happens with the person in mind.

The committee further discussed the evidence (B1.3.1 Contextual risk assessment; moderate quality) which described the importance of engagement to build relationships and understand the risk in the context of people’s lives. The evidence highlighted that visiting people in their homes when making assessments could help professionals decide on interventions that were tailored to people’s strengths and needs. The committee agreed with this evidence and in combination with their experiential knowledge, recommended risk assessments be conducted over several contacts, including home visits. They agreed this recommendation would ensure that a comprehensive and person-centred approach to risk assessment is achieved, and could be a way of minimising any future risks. They also agreed that it could address some of the concerns raised in the evidence (B2.2.1 Definition and concept of risk; moderate quality) regarding the varied perceptions about risk between professionals and adults with complex needs. The committee agreed that by building a relationship, this would be a step toward addressing some of these differences. However, the committee also acknowledged that there may be situations when conducting a risk assessment over several contacts may not be appropriate, for example when there is an escalation of need and a risk assessment is needed urgently, and within a short time-frame. The committee therefore agreed on a recommendation to address this.

Risk assessment – conducting the assessment

The committee discussed the evidence (B1.1.1 Sharing responsibility and decision-making; low quality) that highlighted that the benefits of involving people in decision making would lead to them to feeling content. They agreed that by enabling active participation in the risk assessment, this would encourage a person to be engaged not only at the assessment stage, but in other aspects of their care. Expanding on from this, the committee discussed other qualitative evidence (B2.3.2 Risk choices and adaptive strategies; moderate quality) that suggested risk-taking should be planned for to avoid harmful impacts on the person and others. The committee used the evidence, supported by their experience in practice, to recommend engaging the person in discussions around advance care planning, including a risk management plan. They agreed with the evidence that this would be way of preventing harmful impacts. The committee discussed that planning together with the person would be a way of identifying what an individual wants, and finding solutions to risk that would be appropriate and achievable to them.

The committee discussed that safeguarding issues can be noticed in the risk assessment process and that it is therefore a legal duty in line with the Care Act 2014 that the social worker adheres to local policies to keep the person safe.

Following on from the discussions related to planning together with the person, the committee used the Care Act 2014, to discuss the importance of tailoring a risk assessment to a person’s strengths. They discussed the importance of using a person’s strengths to protect their independence and maintain their wellbeing, and agreed it was important for people to recognise and use their strengths in order to manage their risks. Such knowledge would help social workers make an informed decision on the severity of the potential harms, the reasonable likelihood of harms occurring, and their potential consequences. It would also help to explore the attitudes of the person at risk towards risk and what risk means to them. Such approaches will help social workers to identity the resources available to the person at risk, which will promote a person-centred approach to developing a risk management plan that is acceptable to the person. In the absence of national definitions for risk, the recommendation may also promote a more standardised approach to assessing risk, without overreliance on generic risk categories which do not take personal circumstances into account. The committee were aware that it is inevitable that there will always be an element of subjectivity to risk assessments, but agreed that the benefits of a person-centred risk management plan resulting from the recommendation, would outweigh any of these concerns.

The committee used the evidence (B2.2.1 Definition and concept of risk; moderate quality; B2.3.1 Risk as a complex concept; low quality) and their experience to discuss that different perspectives of risk could result in assumptions regarding capacity. The committee agreed that they would not be able to resolve different perspectives of risk, and therefore it was essential that social workers were signposted to the Mental Capacity Act 2005, which gives guidance on determining a person’s best interests, based on their wishes and abilities, and not based on any assumptions or bias a social worker might hold. The committee used the Mental Capacity Act to support a recommendation that social workers should take into consideration a person’s previous wishes, if they lacked the capacity to make decisions about risk. The committee agreed that this was in line with achieving a person-centred approach to care and support. The committee discussed that the recommendation to highlight not assuming a lack of capacity, could lead to social workers not assessing capacity at all. They wanted to avoid such situations, as they recognised in practice, there would be times when people make decisions that would put them at risk and they would need support and guidance from health and social care professionals. The committee, therefore, made a recommendation for social workers to consider an assessment of capacity when a person has made a decision that is likely to result in significant risk, in order to best understand the person’s specific situation, their past actions and as such gain a wider picture of their individual risk status. In such assessments it would also be useful to gain an understanding of the person’s circumstances and to see whether an assessment for capacity is really needed the committee recognised, based on experience, the importance of the perspectives of people close to the person and members of the multidisciplinary team. They therefore recommended that their views should be taken into consideration.

The committee discussed the evidence (B2.2.1 Definition and concept of risk; moderate quality) that described the mixed perceptions of risk and what the word ‘risk’ means among professionals and adults with complex needs. The evidence also highlighted that there could be differences in perceptions of whether a risk was positive or negative. The committee used this evidence, drew upon the shared decision making guideline and their experience in practice to discuss the challenges associated with this. They discussed that using terminology which is not understood by everyone, could mean potential situations related to harm and danger are not identified, and not addressed. The committee agreed that it was essential to use language that could be understood by all, and would not have different meanings between different people. They agreed on a recommendation, and included some examples of words, to guide social workers working with risk assessment.

The committee discussed some of the evidence (B1.1.1 Sharing responsibility and decision-making; low quality; B1.2.1 Facilitating open discussions; low quality) that suggested there were perceived benefits to using risk checklists when assessing people at risk, particularly when addressing contentious issues such as financial abuse. The checklists reportedly enabled the person at risk to have more open discussions with social workers and other practitioners, and to decide collaboratively on the most acceptable and least intrusive approaches to manage risk. The committee discussed this evidence and agreed that structured risk checklists can provide a useful means for gathering information and promoting joint discussions between the person and the social worker around risk, as well as between professionals. They, therefore, agreed on a recommendation for using a checklist to promote discussion. The committee discussed, based on their knowledge and expertise, some of the disadvantages to risk assessment tools, such as being poorly defined and not validated. Their experience also suggests that they may not necessarily be effective in improving risk assessment and management as checklists could potentially be a barrier to holistic assessments, since it could encourage a rigid adherence to topics on the list rather than a thorough discussion. However, on balance, the committee agreed that combined with the previous recommendations regarding social workers taking the time to get to know the person and their personal circumstances before making decisions around risk, a recommendation for using checklists to promote discussion could provide an additional and useful supplement to the risk assessment process. They also agreed to use their practice experience to highlight in a recommendation that a risk assessment should include discussions regarding past causes of escalation of need, and what has worked well previously. They agreed that by actively enabling a discussion around previous risks, they would avoid potential harm from social workers relying on a checklist, and the risk of an assessment which was not person-centred and did not consider the person’s circumstances. Following on from this, the committee acknowledged that, in the absence of standardised definitions of risk, risk assessments can potentially place too much emphasis on the use of generic risk categories such as ‘high’ and ‘low’ risk, which do not distinguish the severity of potential harms from their likelihood, and do not take into account the different contexts and choices of the person at risk. They therefore agreed that it was important to highlight this in a recommendation.

Stemming from the discussions around how a risk assessment should be conducted, and evidence (B2.2.1 Definition and concept of risk; moderate quality) around the different definitions of risk, the committee raised the importance of the social worker considering their personal bias and values when conducting a risk assessment. They committee discussed that there could be situations when they may misjudge a person’s preferences as a result of unconscious bias. They gave some examples, such as assuming frail people do not want to participate in physical activities. The committee wanted to ensure that everyone undergoing a risk assessment is treated equally, are offered the same opportunities and any preconceptions a social worker may have about risk do not disadvantage people. They agreed to make a recommendation highlighting these issues, and recognised it was supported by the Social Work England’s Professional Standards.

Following on from discussions around personal bias, the committee used their experiential knowledge, as well as some of the evidence (B2.2.1 Definition and concept of risk; moderate quality) around different perspectives of risk, and raised concerns around refusal of care by social workers who disagree with decisions people make if they perceive them as risky or unwise. The committee agreed that such situations can present professionals with challenging issues especially when decisions can lead to harm for the person. However, aware of Principle 3 of the Mental Capacity Act 2005, the committee agreed to make a recommendation that highlighted that social workers should respect a person’s rights to make an unwise decision. They agreed it was necessary to highlight that, in line with the social worker’s duty of care, disagreements in decisions made must not be used as a reason to refuse care even if the social worker perceives these decisions to be risky or unwise. They also highlighted that social workers have a duty to continue to work with people, regardless of their decisions, to try and minimise risk to them. Following on from this, the committee agreed that it was also important to highlight the ways in which social workers can work toward providing the best care for someone when they have been assessed as lacking capacity. The committee discussed that they must continue to keep the person’s best interests in mind by using the best interest checklist in line with section 4 of the Mental Capacity Act ) including identifying whether there is a Lasting Power of Attorney or court-appointed deputy with appropriate decision-making powers to make best interests decisions.

This would mean that the social worker can ensure that any restrictions made are proportionate and justified.

The committee discussed that many of the recommendations described above, regarding how to conduct risk assessments, use of checklists, decisions made regarding unwise choices, and assessment for capacity, would all result in the recording of information regarding a person’s risk to themselves and to others. The committee agreed that all the necessary agencies should be provided with information about a person’s risks, and supported this with a recommendation. This would be of benefit to the person, as people relevant in their care gain a wider understanding of their situation and are able to better support them. It would also benefit those around the person who may be affected by a person’s assessment of risk. However, the committee were aware that it is within a person’s rights to not give consent for their information to be shared. Therefore, they agreed it was necessary to highlight the Human Rights Act to support social workers to balance a person’s right to not give consent with regard to sharing information, with the potential risks involved in withholding information that could lead to harm to the person or those around them.

Risk assessment – recording and reviewing the assessment

Discussions around sharing information regarding risks, led the committee to discuss cases that involve risks of serious harm. Practical dilemmas identified through the evidence (B2.3.1 Risk as a complex concept; low quality) included balancing the needs and rights of individuals in making certain choices in relation to risks, with the duty of care that social workers and other practitioners have in terms of intervening to safeguard individuals from potential harm as a consequence of risk-taking. Also aware of the differences highlighted in the evidence (B2.3.1 Risk as a complex concept; low quality) with how levels of risk were defined and conceptualised between professionals, and from their own experience, the committee discussed that this could lead to tensions across different organisations and among different practitioners. Therefore, the committee were keen to emphasise the need to balance any competing demands and perspectives of different organisations and for different practitioners to exercise professional judgement. To achieve this, they recommended that, in complex situations (for example these could be situations where there are many different opinions in the multidisciplinary team, potentially different complex harms or where one action to avoid one risk might bring about a further risk), social workers co-ordinate a case conference to share information. The committee discussed the potential benefits that would be gained from the recommendation, including encouraging collaboration and promoting shared decision-making across different service providers and practitioners, in terms of assessing and managing risk. They agreed this would promote joint discussions and enable a coordinated risk management plan to be created.

Following on from the discussion regarding differences in defining levels of risk, the committee recognised the importance of involving the person, as well as their family or carers. They discussed that involvement of the person would enable a person-centred approach to a risk management plan, with their preferences taken into consideration. They also recognised that a person’s family or carer may best understand the person, and involving them in a case conference would be beneficial as they could provide valuable input and contributions to the risk management plan. The committee discussed however, that some risk management meetings could be difficult and upsetting for the person to be involved in, and they agreed that the social worker should think about each individual person and their situation, and make a judgement on the appropriateness of their involvement. Similar to this, there may be safeguarding concerns, or other risk concerns, with involving family or carers in case conference. Therefore, the committee made a recommendation for social workers to involve people and their family or carers, only when safe and appropriate to do so.

The committee also discussed the relevance of formally recording differences of opinion in risk assessment. They agreed that the same justification, as within the Need Assessment section discussed above, would be valid here and also made a recommendation relevant to formally recording differences of opinion about a risk assessment.

Leading on from discussions of varying opinions, the committee discussed changes to a person’s risk status. They discussed, using their experience that given the population of adults with complex needs, a person’s situation and circumstance can change often and at times unexpectedly. In order to make sure risk assessments are relevant and up to date, the committee made a recommendation to guide social workers as to when risk assessments should be reviewed. The committee agreed that this recommendation was important to ensure the safety of people, and to continue to provide the best care for them depending on their individual circumstances. It would also aim to ensure that risks are either prevented, or managed early and do not lead to crises.

Risk assessment – organisational support

The committee discussed the evidence (B1.4.1 Organisational support for risk management; low quality) that indicated that where more positive organisational cultures and acceptance towards risk-taking existed, and providing the level of risk is deemed acceptable, then professionals feel more supported to avoid unduly defensive practice. This can lead to supporting risk-taking decisions which accord with the wishes and needs of the person at risk. However, the evidence (B2.4.2 Knowledge & training; low quality) also highlighted that most social workers had not received specific education on risk to prepare them for the complex challenges that may be faced when working with a person at risk. Including, for example, the potential for staff to face adversity in terms of safety if they are subjected to behaviours such as aggression and threats. The evidence (B2.4.2 Knowledge & training; low quality; B2.4.3: Staff safety; very low quality) suggested that an organisational strategy would need to be underpinned by education and training to enable social workers and other practitioners to develop the necessary skills required to work with people with complex needs. Therefore, the committee made a number of recommendations to ensure that organisations have relevant training, continuous professional development (including legal literacy, multi-agency training and de-escalation training to manage challenging behaviour appropriately) and supervision structures in place to support staff to assess risks thoroughly, in terms of risks to both the person at risk but also their own personal safety.

The committee discussed that the benefits gained through multi-agency education and training, would include a more in-depth and shared understanding about the complex decisions needed when assessing and managing risk, and should promote a greater understanding of the different professional roles involved in risk assessment and management. This should lead to greater co-operation between health and social services and enable practitioners to apply their knowledge and skills in practice and provide service users with a more person-centred and human rights based approach to risk assessment and management. The committee also agreed that these recommendations would support social workers to make decisions with the person in mind, and with the person’s best interests. They agreed the recommendations would support the social worker to make decisions that, although may be deemed a risk, would be beneficial to the person’s freedom.

The committee acknowledged that the evidence in this review did not cover all aspects or situations when a person lacks capacity. They were aware of current NICE guidance in the area, and agreed to make a recommendation to sign-post to that guideline.

The committee also made a research recommendation to address the gap in the evidence relating to the use of validated approaches to social work risk assessment. The committee were particularly interested in recommending research to define and evaluate models of social work risk assessment across a range of settings and different groups of people with complex needs to improve the evidence base in the long term and inform future guidelines.

Cost effectiveness and resource use

The recommendations reinforce current legislation and usual practice. These recommendations are unlikely to lead to any increase in resource use or cost.

The recommendations should strengthen person-centred care. This should also improve the identification of risks and achievable expectations allowing for better planning and consequently improvements in quality of life. There may also be cost savings from identifying risks more effectively and preventing or tackling them earlier when intervention is less costly. Setting person centred goals may also prevent wasted resources on goals which are unachievable or which are not in line with the person’s own wishes.

Other factors the committee took into account

When making the recommendations, the committee also aimed to ensure individual choice is respected and fundamental human rights upheld in relation to decision-making. They therefore took into account relevant legislation, including, the Mental Capacity Act 2005 and the Mental Health Act 2007 and the Human Rights Act 1998 as well as guidance on the assessment of mental capacity in the NICE decision-making and mental capacity NG108 (2018). They discussed that there are some conditions that fluctuate such as some types of cognitive impairment (for example impairments affecting executive functions) or acquired brain injury. They noted that the Mental Capacity Act 2007 would still be relevant because it applies whether the impairment or disturbance is permanent or temporary but they also cross-referred to a specific recommendation of the NICE guideline on decision-making and mental capacity that highlights the challenges of assessing capacity in such circumstances. The committee were also aware that people at risk include a wide variety of people with individual needs and living situations, and decisions around risk can be influenced by culture, personal beliefs, and coping strategies. They therefore took into consideration the Equality Act 2010 and standards of practice (according to Social Work England’s professional standards or the British Association for Social Workers’ Professional Capabilities Framework ) when making the recommendations.

Recommendations supported by this evidence review

This evidence review supports recommendations 1.1.6, 1.1.8. 1.1.13, 1.2.13, 1.2.16 to 1.2.45. It also supports research recommendation 2 on the use of tools and checklists to support a social worker risk assessment.

References – included studies

O’Hare 2013

Stevenson 2019

Taylor 2013

BASW PCF competency 7 - skills and interventions Experienced social worker 7 - Skills and interventions, www.basw.co.uk .

SWE professional standards 3.2, 3.3, 3.5, 3.6 and 3.7 - Decision making Professional standards guidance - Social Work England.

Appendix A. Review protocols

Review protocol for review question B1: What is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs? (PDF, 482K)

Review protocol for review question B2: Based on the views and experiences of everyone involved, what works well and what could be improved about social work risk assessments with adults with complex needs? (PDF, 493K)

Appendix B. Literature search strategies

Literature search strategies for review question B1: What is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs? (PDF, 484K)

Literature search strategies for review question B2: Based on the views and experiences of everyone involved, what works well and what could be improved about risk assessment with adults with complex needs? (PDF, 511K)

Literature search strategies for economic studies (PDF, 590K)

Appendix C. Effectiveness evidence study selection

Study selection for review question B1: What is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs? (PDF, 354K)

Qualitative evidence study selection

Study selection for review question B2: Based on the views and experiences of everyone involved, what works well and what could be improved about risk assessment with adults with complex needs? (PDF, 354K)

Appendix D. Evidence tables

Evidence tables for review question b1: what is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs.

No evidence was identified which was applicable to this review question.

Evidence tables for review question B2: Based on the views and experiences of everyone involved, what works well and what could be improved about risk assessment with adults with complex needs?

Download PDF (484K)

Appendix E. Forest plots

Forest plots for review question b1: what is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs.

No meta-analysis was conducted for this review question and so there are no forest plots.

Appendix F. GRADE and/or GRADE-CERQual tables

Grade tables for review question b1: what is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs, grade cerqual tables for review question b2: based on the views and experiences of everyone involved, what works well and what could be improved about social work risk assessment with adults with complex needs.

Download PDF (498K)

Appendix G. Economic evidence study selection

Study selection for review question: what is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs.

A single economic search was undertaken for all topics included in the scope of this guideline. See Supplement 2 for further information.

Appendix H. Economic evidence tables

Economic evidence tables for review question: what is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs, appendix i. economic model, economic model for review question: what is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs.

No economic analysis was conducted for this review question.

Appendix J. Excluded studies

Excluded studies for review question b1: what is the effectiveness of social work approaches to assessing and reviewing risk with adults with complex needs, table 15 excluded studies and reasons for their exclusion.

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Excluded studies for review question B2: Based on the views and experiences of everyone involved, what works well and what could be improved about social work risk assessments with adults with complex needs?

Table 16 excluded studies and reasons for their exclusion, excluded economic studies.

No economic evidence was identified for this review. See supplementary material 2 for further information.

Appendix K. Research recommendations – full details

Research recommendations for review question B2: Based on the views and experiences of everyone involved, what works well and could be improved about the use of tools and checklists social work risk assessments with adults with complex needs? (PDF, 391K)

BASW PCF competency 7 - skills and interventions Experienced social worker 7 - Skills and interventions | www ​.basw.co.uk .

Evidence reviews underpinning recommendations 1.1.6, 1.1.8, 1.1.13, 1.2.13, 1.2.16 to 1.2.45 and research recommendation 2 in the NICE guideline

These evidence reviews were developed by the National Guideline Alliance

Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn.

• Cite this Page Risk assessment: Social work with adults experiencing complex needs: Evidence review B. London: National Institute for Health and Care Excellence (NICE); 2022 May. (NICE Guideline, No. 216.)
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• NICE Evidence Reviews Collection

Related NICE guidance and evidence

• NICE Guideline 216: Social work with adults experiencing complex needs

Supplemental NICE documents

• Supplement 1: Methods (PDF)
• Supplement 2: Economic searches (PDF)

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• Right care, first time: a highly personalised and measurement-based care model to manage youth mental health. [Med J Aust. 2019] Right care, first time: a highly personalised and measurement-based care model to manage youth mental health. Hickie IB, Scott EM, Cross SP, Iorfino F, Davenport TA, Guastella AJ, Naismith SL, Carpenter JS, Rohleder C, Crouse JJ, et al. Med J Aust. 2019 Nov; 211 Suppl 9:S3-S46.
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Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults : A Review

• 1 Division of Geriatrics, Duke University, Durham, North Carolina
• 2 Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
• 3 Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
• 4 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
• 5 Marcus Institute for Aging Research & Department of Medicine, Hebrew SeniorLife, Boston, Massachusetts
• JAMA Clinical Guidelines Synopsis Guidelines on Falls Prevention in Older Adults Peggy B. Leung, MD; Jason T. Alexander, MD; Karin E. Ouchida, MD JAMA

Importance   Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures.

Observations   Falls result from age-related physiologic changes compounded by multiple intrinsic and extrinsic risk factors. Major modifiable risk factors among community-dwelling older adults include gait and balance disorders, orthostatic hypotension, sensory impairment, medications, and environmental hazards. Guidelines recommend that individuals who report a fall in the prior year, have concerns about falling, or have gait speed less than 0.8 to 1 m/s should receive fall prevention interventions. In a meta-analysis of 59 randomized clinical trials (RCTs) in average-risk to high-risk populations, exercise interventions to reduce falls were associated with 655 falls per 1000 patient-years in intervention groups vs 850 falls per 1000 patient-years in nonexercise control groups (rate ratio [RR] for falls, 0.77; 95% CI, 0.71-0.83; risk ratio for number of people who fall, 0.85; 95% CI, 0.81-0.89; risk difference, 7.2%; 95% CI, 5.2%-9.1%), with most trials assessing balance and functional exercises. In a meta-analysis of 43 RCTs of interventions that systematically assessed and addressed multiple risk factors among individuals at high risk, multifactorial interventions were associated with 1784 falls per 1000 patient-years in intervention groups vs 2317 falls per 1000 patient-years in control groups (RR, 0.77; 95% CI, 0.67-0.87) without a significant difference in the number of individuals who fell. Other interventions associated with decreased falls in meta-analysis of RCTs and quasi-randomized trials include surgery to remove cataracts (8 studies with 1834 patients; risk ratio [RR], 0.68; 95% CI, 0.48-0.96), multicomponent podiatry interventions (3 studies with 1358 patients; RR, 0.77; 95% CI, 0.61-0.99), and environmental modifications for individuals at high risk (12 studies with 5293 patients; RR, 0.74; 95% CI, 0.61-0.91). Meta-analysis of RCTs of programs to stop medications associated with falls have not found a significant reduction, although deprescribing is a component of many successful multifactorial interventions.

Conclusions and Relevance   More than 25% of older adults fall each year, and falls are the leading cause of injury-related death in persons aged 65 years or older. Functional exercises to improve leg strength and balance are recommended for fall prevention in average-risk to high-risk populations. Multifactorial risk reduction based on a systematic clinical assessment for modifiable risk factors may reduce fall rates among those at high risk.

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Colón-Emeric CS , McDermott CL , Lee DS , Berry SD. Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults : A Review . JAMA. Published online March 27, 2024. doi:10.1001/jama.2024.1416

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Risk Evaluation for Formaldehyde

Chemical Group: N/A

CASRN: 50-00-0

Risk Evaluation Initiated: December 2019

Docket:  EPA-HQ-OPPT-2018-0438

Staff Contact:  Jeffrey Putt [email protected] (202) 564-3703

On March 15, 2024, EPA released the draft risk evaluation under the Toxic Substances Control Act (TSCA) for formaldehyde for public comment and peer review. 

Formaldehyde’s use as a pesticide is also undergoing a separate review under the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA). The FIFRA risk assessment, which addresses the pesticidal uses of formaldehyde, will be released in 2024 on docket  EPA-HQ-OPP-2015-0739 .

Find other information about other chemicals undergoing risk evaluations under TSCA . 

On this page:

Risk Evaluation Findings

Background on formaldehyde.

• Uses of Formaldehyde

Recent Activities and Opportunities for Public Comment

• Risk Evaluation and Supporting Documents

On another page:

• 40 CFR Part 770 - Formaldehyde Emission Standards for Composite Wood Products

EPA preliminarily finds that formaldehyde poses unreasonable risk to human health. However, EPA notes that these risks may not apply to everyone, everywhere and describes some of the sources of uncertainties in EPA’s findings.

Due to its varied sources, people are routinely exposed to formaldehyde in indoor and outdoor environments, often from more than one source at a time. High levels of exposures to formaldehyde can cause health problems when inhaled and if it is absorbed into the skin. Inhaling high levels of formaldehyde for a short period of time can cause sensory irritation such as eye irritation. Inhaling formaldehyde for longer periods of time can damage the lungs and increase asthma and allergy-related conditions, sensory irritation, reproductive toxicity, and cancer. Skin contact with products containing formaldehyde can also cause allergic reactions.

In the draft risk evaluation, EPA evaluated the risks that arise from ways in which people may be exposed to formaldehyde from the production and use of products that are subject to TSCA - as opposed to exposures from those products that are excluded from TSCA (such as pesticides and exposures from sources of formaldehyde that are biogenic such as breathing and the decomposition of leaves) and exposures from other sources of formaldehyde.

EPA found that workers who are in workplaces where formaldehyde is used are at the most risk from formaldehyde exposure. Workers may be exposed to formaldehyde by inhaling it after it is released into the air or by making skin contact with formaldehyde-containing materials. EPA made these conclusions without assuming that worker protections, such as wearing protective equipment, were in place, although EPA is aware that many employers do take measures to protect the safety of their workers.

EPA also found that people who frequently use certain consumer products that contain formaldehyde are at risk. These products included car waxes, some crafting supplies, and fabrics or leather goods treated with formaldehyde. However, a person’s risk from these products depends on how long and how frequently the products are used, and in many cases, exposures from these products are at the same or lower levels than exposures from other sources of formaldehyde in the home such as candles or cooking. People may also be exposed to more formaldehyde in their homes if the homes are newer or contain newer furniture because building products and furniture can release formaldehyde at higher levels when newly formulated. Lastly, people living near facilities releasing formaldehyde may have higher exposures than those located further away.

EPA also evaluated formaldehyde’s impact on the environment and found that formaldehyde is not expected to last long in water, sediment, or soil based on its physical and chemical properties. EPA did not identify risk of injury to the environment that would contribute to the unreasonable risk determination for formaldehyde.

Formaldehyde is a colorless, flammable gas at room temperature and has a strong odor. Formaldehyde is found nearly everywhere. People and animals produce and release formaldehyde. Formaldehyde is produced when organic material including leaves, plants, and woodchips decay. Formaldehyde is also produced and released into the air when things burn, such as when cars emit exhaust, when furnaces and stoves operate, and through forest fires, burning candles, and smoking. Finally, formaldehyde is used to make many products including composite wood products and other building materials, plastics, pesticides, paints, adhesives, and sealants. Information from the 2016 Chemical Data Reporting (CDR) for formaldehyde indicates that the reported production volume is between 1 billion and 5 billion lbs/year (manufacture and import).

Uses  of Formaldehyde

In the final scope, EPA identified conditions of use associated with the importing; processing; distribution in commerce; industrial, commercial and consumer uses; and disposal of formaldehyde, for example:

• Adhesive and sealants;
• Pesticides and agricultural chemicals;
• Lawn and garden products;
• Personal care products;
• Plastic materials;
• Resins, glues, and binders;
• Paper manufacturing;
• Various petrochemical processes and products;
• Wood product manufacturing; and
• Textiles, apparel, and leather.

The above listed conditions of use are ways that a person or the environment could be potentially exposed to this chemical. However, when conducting a risk evaluation, EPA also considers the hazards (i.e. health effects or environmental impacts) that could occur from coming in contact with a chemical.

On March 15, 2024, EPA released the draft risk evaluation for this chemical for public comment and peer review. EPA will accept public comments on the draft risk evaluation for 60 days following publication in the Federal Register via docket EPA-HQ-OPPT-2023-0613  at regulations.gov .

EPA will hold a virtual peer review public meeting for of the Science Advisory Committee on Chemicals (SACC) to discuss the draft risk evaluation from May 20-23, 2024. EPA will also hold a virtual preparatory public meeting for the SACC and the public to consider and ask questions regarding the scope and clarity of the draft charge questions on May 7, 2024. View the SACC website for more information on the May 2024 meetings .

In August 2020, EPA published a final scope document outlining the hazards, exposures, conditions of use, and the potentially exposed or susceptible subpopulations the agency expects to consider in its risk evaluation. The agency released the draft scope in April 2020 and took public comments on the draft document.

• Read the final scope of the risk evaluation for this chemical and EPA’s response to comments on the draft scope .
• View the dockets for this chemical, EPA-HQ-OPPT-2023-0613 and  EPA-HQ-OPPT-2018-0438 on www.regulations.gov.

As EPA continues to move through the risk evaluation process there will be additional opportunities for public comment, including a public comment period on the draft risk evaluation.  In addition to public comment periods, EPA will continue to engage with stakeholders as it refines the risk evaluation and stakeholders should reach out to EPA via the staff contact to engage with the agency.

Draft Risk Evaluations and Supporting Documents

The draft risk evaluation has a different structure compared to previous risk evaluations released by EPA. Rather than one document, the risk evaluation for formaldehyde includes several documents that culminate in an environmental risk assessment, human health risk assessment, and unreasonable risk determination. 

Read the Federal Register notice .

• Executive Summary:  Formaldehyde Draft RE Executive Summary March2024 (pdf) (309 KB)
• Conditions of Use:  Formaldehyde Draft RE Conditions of Use March 2024 (pdf) (453.9 KB)
• Chemistry, Fate, and Transport Assessment:  Formaldehyde Draft RE Chemistry, Fate, and Transport Assessment March 2024 (pdf) (746.3 KB)
• Environmental Release Assessment:  Formaldehyde Draft RE Environmental Release Assessment March 2024 (pdf) (1.8 MB)
• Environmental Hazard Assessment:  Formaldehyde Draft RE Environmental Hazard Assessment March 2024 (pdf) (812.8 KB)
• Environmental Exposure Assessment:  Formaldehyde Draft RE Environmental Exposure Assessment March 2024 (pdf) (625.8 KB)
• Human Health Hazard Assessment (supported by EPA’s Draft IRIS Assessment for Formaldehyde):  Formaldehyde Draft RE Human Health Hazard Assessment March 2024 (pdf) (1.1 MB)
• Occupational Exposure Assessment:  Formaldehyde Draft RE Occupational Exposure Assessment March 2024 (pdf) (5 MB)
• Consumer Exposure Assessment:  Formaldehyde Draft RE Consumer Exposure Assessment March 2024 (pdf) (1.4 MB)
• Indoor Air Exposure Assessment:  Formaldehyde Draft RE Indoor Air Exposure Assessment March 2024 (pdf) (1.4 MB)
• Ambient Air Exposure Assessment:  Formaldehyde Draft RE Ambient Air Exposure Assessment March 2024 (pdf) (1.7 MB)
• Unreasonable Risk Determination:  Formaldehyde Draft RE Unreasonable Risk Determination March 2024 (pdf) (465.9 KB)
• How EPA Evaluates the Safety of Existing Chemicals
• Prioritizing Existing Chemicals for Risk Evaluation
• Risk Evaluations for Existing Chemicals
• Risk Management for Existing Chemicals

• Open access
• Published: 05 April 2024

Antibiotic use in infants at risk of early-onset sepsis: results from a unicentric retrospective cohort study

• Catalina Morales-Betancourt   ORCID: orcid.org/0000-0001-9989-0530 1 , 2 ,
• Diego Fontiveros-Escalona 1 ,
• Adriana Montealegre-Pomar 3 , 4 ,
• Tania Carbayo-Jiménez 1 ,
• María Palomares-Eraso 1 ,
• Concepción de Alba-Romero 1 ,
• Elena Bergón-Sendín 1 , 5 ,
• Maria Teresa Moral Pumarega 1 , 5 &
• Carmen Pallás-Alonso 1 , 5  

BMC Pediatrics volume  24 , Article number:  245 ( 2024 ) Cite this article

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Antibiotic use for early-onset sepsis represents a high percentage of antibiotic consumption in the neonatal setting. Measures to assess infants at risk of early-onset sepsis are needed to optimize antibiotic use. Our primary objective was to assess the impact of a departmental guideline on antibiotic use among term infants with suspected EOS not confirmed, in our neonatal unit.

Retrospective cohort study, to compare antibiotic use in term infants during a baseline period of January to December 2018, and a postintervention period from October 2019, to September 2020, respectively. The primary outcome was antibiotic use measured by days of therapy, the antibiotic spectrum index, the antibiotic use rate, and the length of therapy.

We included 71 infants in the baseline period and 66 infants in the postintervention period. Compared to those in the baseline period, there was a significant reduction in overall antibiotic measures in the postintervention period, ( P  < 0.001). The total days of therapy/1000 patient-days decreased from 63/1000 patient-days during the baseline period to 25.8/1000 patient-days in the postintervention period, representing a relative reduction of 59%. The antibiotic use rate decreased by more than half of the infants, from 3.2% during the baseline period to 1.3% in the postintervention period.

Conclusions

The use of a departmental guideline to assess infants at risk of early-onset sepsis based on their clinical condition and prompt discontinuation of antibiotics, is a simple and low-cost measure that contributed to an important decrease in antibiotic use.

Peer Review reports

The incidence of early-onset sepsis (EOS) has decreased in recent decades, and in 2018, the incidence reported in Spain was 1–1.2 per 1000 live births [ 1 ]. However, the incidence of suspected EOS is 6–16 times greater and represents approximately 10% of antibiotic use in the neonatal intensive care unit (NICU) [ 2 ].

The European Standards of Care for Newborn Health (ESCNH) highlights the role of reducing unnecessary or prolonged antibiotic therapy as a main step in improving health outcomes and decreasing the emergence of multidrug-resistant bacteria [ 3 ]. Multiple quality improvement initiatives and antibiotic stewardship programs have been trialed in order to reduce antibiotic overuse, however, most of them are based on a multivariate risk assessment using a risk calculator model [ 4 , 5 ]. Despite the urge to optimize antibiotic consumption, the use of antibiotics in infants without proven EOS ranges from 70%, according to recent reports [ 6 ].

Our center has successfully implemented a quality improvement initiative to optimize antibiotic use in very low birth weight infants, through departmental guidelines and an affordable surveillance system, a significant reduction in antibiotic exposure was observed [ 7 ]. Following current evidence and previous experience, our NICU developed a quality improvement initiative to endorse the ESCNH standard for managing infants at risk of EOS through departmental guideline based on clinical observation and prompt antibiotic discontinuation.

The main objective of this study was to assess the impact of a departmental guideline on antibiotic use among term infants with suspected EOS not confirmed, in our NICU.

Setting and study design

This study was performed in the neonatology department of the 12 de Octubre University Hospital in Madrid, Spain. Our NICU is a IIIC-level unit. In our unit, the clinical observation of an infant with perinatal risk factors for EOS but a good appearance is routinely made while rooming-in with the mother. A medical examination is performed at 2 h after birth; if there are no signs of EOS, the mother–infant dyad is observed in the maternity ward until discharge.

We performed a retrospective cohort study to compare antibiotic use among term infants born between a baseline period of January to December 2018, and a postintervention period from October 2019, to September 2020.

We included all term newborn infants born in the maternity ward who had received antibiotics for suspected EOS during the first 3 days of life. We excluded outborn infants, those with major congenital malformations, and those treated for localized infections or surgical prophylaxis. We excluded infants with confirmed EOS from the analysis because antibiotic use is justified and the opportunity to reduce antibiotic overuse is limited.

Implementation of a departmental guideline

Until 2019, the neonatology department didn’t have a guideline for the assessment of infants with risk factors for EOS and clinical signs. If an infant developed clinical signs or symptoms of EOS during admission, laboratory tests were performed, including blood cultures if antibiotics were to be started. The empiric antibiotic regimen for EOS included ampicillin, gentamycin. Cefotaxime was reserved for critically ill infants or those with suspected meningitis. If the blood culture was negative, antibiotic therapy was continued for 5–7 days.

In April 2019 a departmental guideline was developed for the assessment and clinical management of newborns born at > 35 weeks gestation who were at risk of EOS in line with the ESCNH (see flowchart in Additional file 1 ). The document defined standard antibiotic therapy durations and highlighted three key factors in the assessment of the symptomatic infants:

Some signs and symptoms may be attributable to noninfectious conditions [ 8 ].

The C-reactive protein (CRP) level may increase as an inflammatory marker; thus, the decision to start antibiotics should not rely only on CRP values [ 9 ].

Antibiotics should be discontinued if blood cultures are negative at 36–48 h, and the use of third-generation cephalosporins should be avoided [ 9 ].

To facilitate implementation and uptake, we decided to allow a period of six months to pass before data collection.

Our primary outcome was antibiotic use, which was assessed using the following measures: days of therapy (DOTs), DOTs/1000 patient-days (PDs), length of therapy (LOT), antibiotic use rate (AUR), antibiotic spectrum index (ASI) and ASI/LOT (see measures in Additional file 2 ) [ 10 , 11 ].

As a secondary outcome, we analyzed the changes in hospital length of stay (LOS) as an indicator of the risk of unsafe care. In addition, we reviewed cases of missed EOS, which were identified by reviewing the clinical records through 28 days of life of all infants included in the study.

Data collection and definitions

We considered the following risk factors for EOS: premature rupture of the membranes (ROM); a duration of ROM > 18 h before delivery; maternal Streptococcus group B (GBS) colonization with inadequate intrapartum antibiotic therapy; a history of previous GBS disease in offspring; and suspicion of intra-amniotic infection, which was defined by either a single maternal intrapartum temperature ≥39ºC or a temperature of 38–38.9 ºC for ≥ 30 min [ 12 ].

We defined suspected EOS as an evaluation for sepsis performed within 3 days of birth at the discretion of the attending neonatologist with empiric antibiotics. EOS was defined as sepsis diagnosed by blood culture within three days of birth [ 9 ].

Statistical analyses

The descriptive statistics included the mean and standard deviation for normally distributed continuous variables, the median and interquartile range (IQR) for nonnormally distributed continuous variables, and the absolute and relative frequencies for categorical variables. Differences between groups were analyzed using the Mann–Whitney U test for quantitative variables and Fisher’s exact test or chi-squared test for categorical variables. The rate ratio and 95% confidence intervals were used to compare the DOTs and AUR between the baseline and postintervention periods. Statistical analyses were performed using Stata version 14 (StataCorp, LLC, College Station, TX).

Patient characteristics

We identified 71 infants in the baseline period and 66 in the postintervention period. The perinatal and clinical characteristics of the included patients are summarized in Table  1 .

• Antibiotic use

The measures of antibiotic use are shown in Table  2 . In the baseline period, there were 14,089 days of total LOS and 461 days of total LOT. In the post-intervention period, there were 12,880 days of total LOS and 173 days of total LOT.

The median LOS significantly decreased from 7 days (IQR, 7–8 days) in the baseline period to 5 days (IQR, 3–7 days) in the postintervention period ( p  < 0.001). None of the patients was readmitted within 28 days.

The incidence of EOS remained stable, and the cases were identified using the approach used in each period. In the baseline period there were 5 cases of EOS and 1 case in the postintervention period.

In this study, following the implementation of a new departmental guideline in line with the ESCNH standards, we observed a significant reduction in overall measures of antibiotic use. In the postintervention period, the use of antibiotics for EOS was halved without any increase in the LOS and there were no cases of missed EOS.

Current recommendations across different societies about managing suspected or proven EOS are homogeneous and concur about decreasing antibiotics overuse. In high-income countries with high rates of pregnancy follow-up and declining incidence rates of EOS, the approach to managing infants at risk should be oriented toward clinical observation, and early discontinuation of antibiotics [ 3 ].

One of the most studied strategies to decrease antibiotic use in the EOS framework involve the implementation of a multivariate risk assessment through a risk calculator. Although it is a tool that requires training and proper interpretation, the results are promising and have led many units to reduce antibiotic consumption [ 5 , 13 ]. What seems to be a constant in the success of the approaches implemented in other units is the educational factor, by highlighting the importance of antibiotic stewardship and making the staph aware of the actions that needs to be taken. In our unit, the implementation of a simple departmental guideline contributed to a reduction in early antibiotic exposure, as indicated by a decreased DOT and less LOS.

A recent study of a large international network revealed that even in the infants treated with antibiotics but without EOS, the median LOT was 4 days, which diverges with the current recommendation for stopping antibiotics within 36–48 h [ 6 , 9 ]. In our cohort the LOT in the post invention period significantly decreased to 2.5 days, which is lower that the median described by Giannoni et al. Additionally in that large cohort, for each infant with proven EOS, 58 infants received antibiotics, in contrast and in a smaller dataset, for each infant with proven EOS, we initiated treatment in 20 infants considering both periods. We also decreased our AUR to 1.3%, which is closer to the goal suggested by the same authors.

Although our sample size was limited, the LOS did not increase as an adverse event and there were no cases of readmission. Furthermore, our results are consistent with those obtained by other groups. As in our study, the implementation of a common guideline based on active antibiotic discontinuation in three Norwegian NICUs, was associated with a significant reduction in antibiotic therapy duration and a 37% reduction in DOT [ 4 ]. Likewise, a strategy based on serial physical examination for suspected EOS in term neonates, within a quality improvement initiative in a NICU in Stavanger, improved antibiotic use measures, reducing by half the antibiotic exposure in the first 3 days of life, declining from 2.9 to 1.3% [ 14 ].

Recently Stocker et al. addressed the basics of the decision-making process regarding early antibiotic use [ 15 ]. Based on our experience, we agree that a straightforward approach that includes an understanding of the unit’s baseline situation and staff training on initiation and early discontinuation of antibiotics may be the most effective way for NICUs to improve their antibiotic use indicators and, consequently, their results.

With this initiative, we propose an approach for the management of infants at risk of EOS oriented toward clinical observation and prompt discontinuation of antibiotics. This affordable and simple approach based on an observation strategy has contributed to reduce unnecessary use of antibiotics in term infants, in line with the recommendations of the ESCNH. Although we look forward toward an ideal strategy for assessing these infants, one model will not fit all the neonatal units. As each unit individualizes and develops its own approach, based on the neonatal population and available resources, we will be closer to narrowing the population exposed to unnecessary antibiotics during the first days of life.

Data availability

All data analyzed during this study are included in this article. Further enquiries are available upon reasonable request to the correspondence author.

Abbreviations

Antibiotic spectrum index

Antibiotic use rate

C-reactive protein

Days of therapy

• Early-onset sepsis

European Standards of Care for Newborn Health

Group B Streptococcus

Interquartile range

Length of stay

Length of therapy

Neonatal intensive care unit

Patient-days

Premature rupture of the membranes

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Acknowledgements

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This study was not supported by any funding or grants.

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Department of Neonatology, 12 de Octubre University Hospital, Avenida de Córdoba S/N, Madrid, 28041, Spain

Catalina Morales-Betancourt, Diego Fontiveros-Escalona, Tania Carbayo-Jiménez, María Palomares-Eraso, Concepción de Alba-Romero, Elena Bergón-Sendín, Maria Teresa Moral Pumarega & Carmen Pallás-Alonso

Escuela de Doctorado, Universidad de Alcalá, Ciencias de la salud, Madrid, Spain

Catalina Morales-Betancourt

San Ignacio University Hospital, Bogotá, Colombia

Adriana Montealegre-Pomar

Pontificia Universidad Javeriana, Bogotá, Colombia

Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), Instituto de Salud Carlos III, RD21/0012/0009, Madrid, Spain

Elena Bergón-Sendín, Maria Teresa Moral Pumarega & Carmen Pallás-Alonso

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Contributions

C.M.B, E.B.S, M.T.M.P, C.P.A conceptualized the design of the study, coordinated and supervised data collection, drafted the initial manuscript, and reviewed the manuscript. T.C.J., M.P.E, C.A.R reviewed the literature and wrote the departmental guideline. A.M.P. contributed to the statistical analysis and interpretation of the data. D.F.E., T.C.J., and M.P.E. contributed to the acquisition of the data. M.T.M.P and C.P.A contributed equally to this work and share last authorship. All authors approved the manuscript for publication and are accountable for the data contained herein.

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Correspondence to Catalina Morales-Betancourt .

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Approval was obtained from the ethics committee of 12 de Octubre University Hospital (22/222). The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

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Informed consent was waived by the ethics committee of 12 de Octubre University Hospital.

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The authors declare no competing interests.

Authors’ information

C.P.A, M.T.M.P and E.B.S. are associated with the network RICORS funded by the Recovery, Transformation, and Resilience Plan 2017–2020, ISCIII, and the European Union–Next Generation EU (ref. RD21/0012/0009). C.M.B. is a Ph.D. student of the Program of Health Sciences, Escuela de Doctorado, Universidad de Alcalá, Alcalá de Henares, Spain.

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Morales-Betancourt, C., Fontiveros-Escalona, D., Montealegre-Pomar, A. et al. Antibiotic use in infants at risk of early-onset sepsis: results from a unicentric retrospective cohort study. BMC Pediatr 24 , 245 (2024). https://doi.org/10.1186/s12887-024-04637-x

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Received : 06 December 2023

Accepted : 10 February 2024

Published : 05 April 2024

DOI : https://doi.org/10.1186/s12887-024-04637-x

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