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Healthcare risk assessment

Gastroenterology and Hepatology Risk Assessment: Deterioration, Procedure Safety and Record Controls

A worked example of how a gastroenterology and liver service finds, scores and controls risks to patients, from missed deterioration and endoscopy harm to medication errors, privacy lapses and weak handovers.

Updated November 2026 8 hazards assessed Review every 6 months Highest risk: Critical to High
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Executive summary

This assessment shows how a gastroenterology and liver service can find, rate and control the risks that matter most to patient safety, consent, privacy and continuity. Eight risks were chosen because they are plausible in endoscopy, liver clinics and ward care. Missed deterioration in patients with liver disease scores highest before controls, followed by procedure harm, medication errors, handover failures and infection spread. Each risk is scored before controls and again after existing and added controls. Most risks fall to Medium or Low once controls are in place, but deterioration stays High because the harm is severe. The first actions are a structured early warning response, a sedation emergency pathway, an alert for high-risk medicines and a closed loop handover checklist. Specialist clinical review is needed before any real use of these scores.

Focus area
Gastroenterology and hepatology care
Setting
Hospital gastroenterology service with an endoscopy unit, inpatient liver care and an outpatient liver clinic for adults
Method
Five by five likelihood and impact risk register

Scope

This assessment covers outpatient and inpatient gastroenterology and hepatology care, including endoscopy, liver clinics, ward review of patients with liver disease and the records and equipment that support them. It looks at risks to patient safety, consent, privacy, staff competence and continuity. Jurisdiction, service size, staffing model and information systems are not specified, so they are assumed for teaching. It does not replace a formal site-specific clinical risk assessment or specialist clinical governance review.

Context

The service has consultant gastroenterologists and hepatologists, specialist nurses, endoscopy technicians, a sedation team, a clinical pharmacist, administrative staff and a shared electronic record. Endoscopy lists run several days a week, a liver clinic follows patients with chronic liver disease and cirrhosis, and ward teams refer inpatients with bleeding, jaundice or fluid problems. Each risk is scored before controls to show its natural level, then again after existing controls and the additional controls proposed. The scores are examples that show method, not a judgment on any real service.

Objectives, assets and stakeholders

The objective is to recognize and treat patients safely, perform procedures without avoidable harm, keep consent and records accurate, protect confidential information and keep surveillance on time. The assets in scope are patients, the endoscopy suite and its equipment, the electronic record, medicines, clinical staff competence and the trust of patients and referring clinicians. Stakeholders include patients and families, consultants, nurses, pharmacists, endoscopy technicians, general practitioners, the infection prevention team and the governance and information governance leads. Every risk has one owner role, and the clinical governance lead reports the register to the service board each quarter.

Risk matrix: before and after controls

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

Before controls

Inherent risk

Risk before controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain Likelihood 5, impact 4, score 20, critical: H01
4 Likely Likelihood 4, impact 3, score 12, high: H06
3 Possible Likelihood 3, impact 3, score 9, medium: H04 H07 Likelihood 3, impact 4, score 12, high: H03 H05 Likelihood 3, impact 5, score 15, high: H02
2 Unlikely Likelihood 2, impact 5, score 10, high: H08
1 Rare

After controls

Residual risk

Risk after controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely
3 Possible Likelihood 3, impact 2, score 6, medium: H06 Likelihood 3, impact 4, score 12, high: H01
2 Unlikely Likelihood 2, impact 2, score 4, low: H04 H07 Likelihood 2, impact 3, score 6, medium: H03 H05 Likelihood 2, impact 4, score 8, medium: H02
1 Rare Likelihood 1, impact 4, score 4, low: H08
  • Low 1 to 4
  • Medium 5 to 9
  • High 10 to 16
  • Critical 17 to 25

Hazard register

A summary first, then the detail for each hazard.

Summary of hazards with scores before and after controls
No.HazardBeforeAfterOwner
H01 Delayed recognition of deterioration in patients with liver disease or bleeding 20 Critical 12 High Clinical lead for inpatient gastroenterology
H02 Procedure harm during endoscopy and sedation 15 High 8 Medium Lead consultant for endoscopy
H03 Medication errors with anticoagulants, immunosuppressants and hepatotoxic drugs 12 High 6 Medium Clinical pharmacist lead
H04 Consent and documentation gaps for procedures and sensitive care 9 Medium 4 Low Clinical governance lead
H05 Privacy breach in clinic and endoscopy records 12 High 6 Medium Information governance lead
H06 Staffing shortages and competence gaps in endoscopy and liver clinics 12 High 6 Medium Service manager for endoscopy
H07 Handover failures and missed follow-up for liver surveillance 9 Medium 4 Low Clinic nurse manager
H08 Infection spread and inadequate endoscope decontamination 10 High 4 Low Infection prevention and control lead
H01

Delayed recognition of deterioration in patients with liver disease or bleeding

Safety Before 20 After 12

Patients with cirrhosis, variceal bleeding or infection can worsen quickly, and early signs such as confusion, low blood pressure or falling urine output are missed or reported too late to the responsible clinician.

Who or what is affected: Inpatients with liver disease, their families and ward nurses

Causes

Subtle early signs in cirrhosis, busy wards and observations that are not escalated when a single score looks acceptable.

Consequences

Avoidable death, prolonged stay, unplanned intensive care transfer and serious harm to patients and families.

Existing controls

  • Ward observations are recorded at set intervals.
  • A consultant reviews inpatients with variceal bleeding within a set time.

Control gaps

Scores are calculated but escalation thresholds are not applied consistently across day and night shifts.

Additional controls

  • Prevent: Use a structured early warning score with a named response for each band.
  • Detect: Audit a sample of charts each month for missed trigger values and late reviews.
Likelihood 5 x impact 4 before; 3 x 4 after Owner: Clinical lead for inpatient gastroenterology Target: Within 30 days Early warning: Patients with a raised score who have no documented clinician review within the set time.
H02

Procedure harm during endoscopy and sedation

Safety Before 15 After 8

Perforation, bleeding, aspiration or an adverse reaction to sedation occurs during endoscopy, or a fault in the scope, suction or monitoring equipment delays a safe procedure.

Who or what is affected: Patients undergoing endoscopy, endoscopy staff and the sedation team

Causes

Complex anatomy, high-risk patients, variable sedation doses and equipment wear that is not tracked by usage.

Consequences

Serious harm, emergency surgery, complaints and loss of public trust in the service.

Existing controls

  • Procedures follow written checklists for fasting, consent and equipment checks.
  • A trained sedation team monitors oxygen saturation and pulse throughout each procedure.

Control gaps

Scope servicing records are not checked against usage counts before each list begins.

Additional controls

  • Respond: Keep an agreed emergency pathway and run airway and bleeding drills each quarter.
  • Recover: Log every adverse event and review it at a monthly team meeting to update guidance.
Likelihood 3 x impact 5 before; 2 x 4 after Owner: Lead consultant for endoscopy Target: Within 60 days Early warning: Unplanned transfers or oxygen support needed during or within two hours of endoscopy.
H03

Medication errors with anticoagulants, immunosuppressants and hepatotoxic drugs

Safety Before 12 After 6

Doses of anticoagulants, immunosuppressants or drugs that can injure the liver are prescribed, transcribed or given wrongly, or are continued after bleeding or drug reaction signs appear.

Who or what is affected: Patients taking long-term medicines, prescribers and ward nurses

Causes

Complex regimens, medicine reconciliation gaps at discharge and dosing changes made without updating the record.

Consequences

Bleeding, drug-induced liver injury, readmission and harm to the patient.

Existing controls

  • A clinical pharmacist reviews new prescriptions for high-risk drugs.
  • Liver function and blood counts are checked at set intervals while on treatment.

Control gaps

Medicine lists brought in from outside clinics are not reconciled before the first specialist review.

Additional controls

  • Prevent: Add an electronic alert for high-risk drug combinations and for dose changes in liver impairment.
  • Detect: Review a monthly report of abnormal liver tests in patients taking high-risk medicines.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Clinical pharmacist lead Target: Within 45 days Early warning: A rise in liver enzymes or any bleeding in a patient on a high-risk medicine within the last month.
H04

Consent and documentation gaps for procedures and sensitive care

Legal and compliance Before 9 After 4

Consent for endoscopy, biopsy or sedation is recorded incompletely, or records of procedure findings and treatment decisions are unclear, so the patient's choices and clinical reasoning cannot be shown later.

Who or what is affected: Patients, clinicians and the service in any complaint or review

Causes

Busy lists, consent taken by staff without specific training and report templates that do not prompt for key facts.

Consequences

Disputed consent, complaints, professional review and distress to patients.

Existing controls

  • Consent forms are signed before every planned procedure.
  • Procedure reports are filed in the electronic record after each list.

Control gaps

Consent audits check that a form is present, not that the discussion of risks and options was recorded.

Additional controls

  • Prevent: Confirm consent with a second staff member before sedation or biopsy begins.
  • Respond: Review any incomplete consent record within 48 hours and inform the responsible clinician.
Likelihood 3 x impact 3 before; 2 x 2 after Owner: Clinical governance lead Target: Within 30 days Early warning: Procedures on a list with a consent field blank or unsigned at the start of the session.
H05

Privacy breach in clinic and endoscopy records

Technology and data Before 12 After 6

Clinic letters, endoscopy images or patient lists are sent to the wrong person, viewed without a clinical need, or left on shared screens and printers, exposing sensitive diagnoses such as viral hepatitis or alcohol-related liver disease.

Who or what is affected: Patients, families, referring practices and staff

Causes

Shared workstations, misaddressed post and staff who look up records out of curiosity.

Consequences

Stigma, distress to patients, complaints and a formal investigation.

Existing controls

  • Staff sign confidentiality terms and complete annual information governance training.
  • Access to the electronic record is role based and logged.

Control gaps

Access logs are reviewed only after a complaint, not as a routine check.

Additional controls

  • Prevent: Check the address on every clinic letter before sending it through a secure system.
  • Recover: Run a breach routine covering containment, a written record and notice to the affected patient.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Information governance lead Target: Within 60 days Early warning: Access logs showing repeated record views by one user without a matching clinic appointment.
H06

Staffing shortages and competence gaps in endoscopy and liver clinics

People Before 12 After 6

Vacancies, sickness or uneven training leave lists run by staff who are not trained or rostered for the task, or cause rushed procedures and missed monitoring.

Who or what is affected: Patients, endoscopy and clinic staff and the wider service

Causes

Recruitment delays, high sickness and training not refreshed when equipment or guidance changes.

Consequences

Missed monitoring, cancelled lists, staff burnout and patient harm.

Existing controls

  • Rotas name a trained member of staff for each list and each sedation session.
  • Competence sign off is required before a nurse can monitor sedation alone.

Control gaps

Cover is planned for scheduled lists but not for late sickness or lapsed competence renewal.

Additional controls

  • Prevent: Keep a bank of trained cover and set a minimum staffing level below which lists are reduced.
  • Detect: Review rota gaps and training expiry dates each week and report them to the service manager.
Likelihood 4 x impact 3 before; 3 x 2 after Owner: Service manager for endoscopy Target: Within 90 days Early warning: Lists with fewer trained sedation staff than the minimum, or any competence sign off that has expired.
H07

Handover failures and missed follow-up for liver surveillance

Operational Before 9 After 4

Results of liver tests, imaging or endoscopy surveillance are not passed on at shift change, clinic transfer or discharge, so patients with cirrhosis miss scans, reviews or treatment changes.

Who or what is affected: Patients with chronic liver disease, general practitioners and clinic staff

Causes

Verbal handovers, several teams sharing one patient and surveillance lists that are not reconciled with the record.

Consequences

Late diagnosis of liver cancer or varices, avoidable admission and loss of patient trust.

Existing controls

  • Clinic letters are sent to the general practitioner after each review.
  • A tracking list of surveillance dates is kept by the clinic team.

Control gaps

Pending results are not listed on the handover sheet, so they can be missed when staff change.

Additional controls

  • Prevent: Add a closed loop handover checklist for pending results at shift change and discharge.
  • Respond: Contact the patient and general practitioner within two working days of any missed review and rebook it.
Likelihood 3 x impact 3 before; 2 x 2 after Owner: Clinic nurse manager Target: Within 60 days Early warning: Surveillance scans or clinic reviews overdue by more than four weeks for patients with cirrhosis.
H08

Infection spread and inadequate endoscope decontamination

Safety Before 10 After 4

Endoscopes or accessories are not fully cleaned, dried or disinfected between patients, or staff are exposed to blood and body fluids, so infections such as bloodborne viruses or resistant bacteria spread.

Who or what is affected: Patients, endoscopy staff and cleaning contractors

Causes

Complex channels, rushed turnaround between patients and cleaning checks that are not recorded.

Consequences

Transmission of infection, outbreaks, patient harm and staff injury.

Existing controls

  • Endoscopes are cleaned and disinfected in a dedicated area after each use.
  • Staff use protective clothing and sharps containers during procedures.

Control gaps

Drying and channel checks are recorded inconsistently when lists overrun.

Additional controls

  • Prevent: Track each endoscope through a logbook with a cycle record and remove any scope with a failed check.
  • Detect: Run periodic microbiological checks on scopes and report results to the infection prevention lead.
Likelihood 2 x impact 5 before; 1 x 4 after Owner: Infection prevention and control lead Target: Within 30 days Early warning: A scope cycle record with a missing or failed check before the scope is used.

Rating method and evaluation

Each risk is rated on two five-point scales. Likelihood runs from Rare to Almost certain, and impact runs from Minor to Catastrophic. Multiplying the two gives a score from 1 to 25, which falls into one of four bands: Low from 1 to 4, Medium from 5 to 9, High from 10 to 16 and Critical from 17 to 25. Low risks are accepted and monitored. Medium risks need routine controls and a named owner. High risks need senior attention and a dated plan. Critical risks need immediate action and direct reporting to the responsible clinical lead. Inherent risk is the score before any controls. Residual risk is the score after existing and additional controls. Impact in patient care is judged by physical harm, length of stay, effect on dignity and privacy, and effect on trust, and a risk is never rated down only because it has not yet happened. Ratings are challenged by the staff who do the work, by a second clinician who was not involved in scoring, and by a review whenever an indicator reaches its threshold. Any change to a clinical rating requires specialist clinical review and a written reason.

Likelihood, impact and rating bands

Likelihood

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

Impact

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

Bands (likelihood x impact)

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

Monitoring, escalation and review

Review this assessment every 6 months, and sooner when an indicator below reaches its threshold.

Early-warning indicators and escalation thresholds
Indicator to watchEscalate when
Patients with a raised early warning score who have no documented clinician review within the set time.Escalate to the clinical lead for inpatient gastroenterology at once, and to the medical director if the delay exceeds one hour on any shift.
Unplanned transfers or oxygen support needed during or within two hours of endoscopy.Escalate to the lead consultant for endoscopy within 24 hours, and to the clinical governance lead for review if two or more occur in one month.
High-risk medicine alerts overridden or abnormal liver tests in patients on these medicines.Escalate to the clinical pharmacist lead at once, and hold the next dose for prescriber review when a rise in liver enzymes is confirmed.
Lists with fewer trained sedation staff than the minimum, or expired competence sign offs.Escalate to the service manager before the list starts, and cancel or reduce the list if the minimum cannot be met.
Scope cycle records with a missing or failed check, or surveillance reviews overdue by more than four weeks.Escalate a failed scope to the infection prevention lead at once, and an overdue surveillance review to the clinic nurse manager within two working days.

Contingency arrangements

If a serious event occurs, such as a sedation emergency, a confirmed breach of records or a suspected outbreak, the duty clinician stops the related list or service, secures the patient and the equipment, and informs the consultant in charge. The infection prevention lead isolates affected scopes and records. The information governance lead contains any breach and follows the local reporting route. Patients and families receive a clear, honest account of what happened and what is being done, and staff receive support after the event.

Prioritized action plan

  1. Introduce a structured early warning response for inpatients with liver disease, owner clinical lead for inpatient gastroenterology, within 30 days.
  2. Agree a sedation emergency pathway and run drills, owner lead consultant for endoscopy, within 60 days.
  3. Add alerts for high-risk drug combinations and reconcile outside medicine lists, owner clinical pharmacist lead, within 45 days.
  4. Add a closed loop handover checklist for pending liver results, owner clinic nurse manager, within 60 days.
  5. Track every endoscope through a logbook with a cycle record, owner infection prevention and control lead, within 30 days.

Conclusion

Safe gastroenterology and hepatology care depends on a few steady habits: structured observation with a named response, checked consent, medicine reconciliation, closed loop handovers, trained staff cover and disciplined decontamination. The highest scores sit with deterioration, procedure harm and medication errors, and each has controls that lower the residual score. Treat the register as a living record, review it on the stated cycle and seek specialist clinical advice for any real diagnosis, treatment or governance decision.

Assumptions and limitations

Assumptions

  • The service is an adult hospital-based unit with an endoscopy suite and a liver clinic, and the legal and regulatory context is not specified.
  • Staff hold recognized clinical qualifications and work under local credentialing and sedation competence rules.
  • Some patients are sedated for endoscopy and some take long-term medicines that need laboratory monitoring.

Limitations

  • The scores are teaching examples and do not describe any real patient group, unit or incident.
  • Clinical guidance, sedation standards and medicines advice change over time, so specialist clinical review is needed before any use.
  • This educational content does not replace licensed medical, nursing or legal advice or a formal clinical risk assessment.

Related frameworks to study

  • Hierarchy of controls
  • Swiss cheese model of layered defenses
  • Structured early warning scoring for deterioration
  • Root cause analysis
  • Plan, do, study, act cycle

Healthcare Risk Assessment

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

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