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Healthcare risk assessment

Hematology and Oncology Risk Assessment: Treatment Safety, Infection and Escalation Controls

A worked example of how a hematology and oncology service finds, scores and controls risks to patients, from dosing errors and neutropenic infection to transfusion, records and 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 hematology and oncology service can find, rate and control the risks that matter most to patient safety. Eight hazards were chosen because they are plausible in daily work with blood cancers, benign blood disorders and their treatments. Neutropenic sepsis and dosing errors score highest before controls because both are common in treatment and can cause serious harm. Bleeding, transfusion, hazardous drug exposure, consent, handover and downtime risks also appear. Most risks fall to Medium or Low once the proposed controls are added, though neutropenic sepsis stays at High because clinical deterioration can be fast. The first actions are a fever pathway for patients with low white cells, independent double checks for high-alert medicines, a transfusion identity check and a tested downtime plan. The example is for teaching only, and every score illustrates method rather than a real service.

Focus area
Hematology and oncology clinical care
Setting
Inpatient and outpatient hematology and oncology service within a general hospital setting
Method
Five by five likelihood and impact risk register with clinical escalation

Scope

This assessment covers a hematology and oncology service, including outpatient infusion, ward care for patients with blood cancers and benign blood disorders, and the handover, records and laboratory links that support them. It covers patient safety, infection control, medicines, consent, records and staff competence. It does not give treatment decisions for any individual patient. Jurisdiction, staffing model and systems are assumptions made for teaching.

Context

The service has consultant hematologists and oncologists, specialist nurses, pharmacists, a laboratory with transfusion support, a chemotherapy preparation unit and an electronic record. Patients receive infusions in a day unit and are admitted for complications such as fever or bleeding. Each risk is scored before controls to show its natural level, then after existing controls and the additional controls proposed here. The scores are for learning only and do not describe any real service.

Objectives, assets and stakeholders

The objective is to deliver safe, effective and timely care for people with blood cancers and blood disorders, to prevent avoidable harm, and to keep the trust of patients, families and referring clinicians. The assets in scope are patients and their safety, medicines and blood products, the chemotherapy preparation unit, laboratory results, electronic records and consent documents, and the skilled staff who deliver care. Stakeholders include patients and carers, consultants and nurses, pharmacists, laboratory and transfusion staff, the hospital governance team, referring general practitioners, and regulators and professional bodies. Each risk has one owner role, and the clinical governance lead reviews the register each quarter and reports to the board.

Risk matrix: before and after controls

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

Before controls

Inherent risk

Risk before controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely Likelihood 4, impact 3, score 12, high: H07 Likelihood 4, impact 5, score 20, critical: H02
3 Possible Likelihood 3, impact 3, score 9, medium: H05 Likelihood 3, impact 4, score 12, high: H03 H06 H08 Likelihood 3, impact 5, score 15, high: H01
2 Unlikely Likelihood 2, impact 5, score 10, high: H04
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 4, score 12, high: H02
2 Unlikely Likelihood 2, impact 2, score 4, low: H05 Likelihood 2, impact 3, score 6, medium: H03 H06 H07 H08 Likelihood 2, impact 4, score 8, medium: H01
1 Rare Likelihood 1, impact 5, score 5, medium: H04
  • 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 Chemotherapy or high-alert medicine dosing error 15 High 8 Medium Chief pharmacist
H02 Neutropenic sepsis from delayed recognition of fever 20 Critical 12 High Consultant hematologist
H03 Bleeding or thrombosis from low platelets or anticoagulation 12 High 6 Medium Clinical nurse specialist for hematology
H04 Wrong blood product or transfusion reaction 10 High 5 Medium Transfusion lead
H05 Hazardous drug exposure and sharps injury for staff 9 Medium 4 Low Occupational health lead
H06 Consent, record and privacy failures 12 High 6 Medium Information governance lead
H07 Handover gaps and competence of cover staff 12 High 6 Medium Ward manager
H08 Laboratory, record system or equipment downtime 12 High 6 Medium Digital services lead
H01

Chemotherapy or high-alert medicine dosing error

Safety Before 15 After 8

A dose is calculated on the wrong body measure, a wrong regimen is selected or a rate is mis-set, so a patient receives too much or too little active drug.

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

Causes

Complex regimens, weight changes between cycles, interruptions and time pressure in the unit.

Consequences

Serious toxicity, treatment delay, admission, harm and a formal investigation.

Existing controls

  • Regimens are built in an electronic prescribing tool with dose limits.
  • A pharmacist verifies each chemotherapy order before preparation.

Control gaps

Double checks are recorded inconsistently, and mid-cycle dose changes are not always re-verified.

Additional controls

  • Prevent: Require an independent double check of dose, body measure and rate before every high-alert infusion.
  • Detect: Audit a monthly sample of orders against the agreed protocol and record any deviation.
Likelihood 3 x impact 5 before; 2 x 4 after Owner: Chief pharmacist Target: Within 45 days Early warning: Chemotherapy orders released without a documented independent double check.
H02

Neutropenic sepsis from delayed recognition of fever

Safety Before 20 After 12

Patients with low white cell counts after treatment develop infection that is not recognized, or fever is not acted on quickly, so sepsis progresses before antibiotics start.

Who or what is affected: Patients with low blood counts, families, nurses and doctors

Causes

Treatment-related low counts, patients who delay calling, and nonspecific early signs in older people.

Consequences

Septic shock, intensive care admission, death and loss of trust in the service.

Existing controls

  • Patients are given written advice to call the unit for a temperature above a set value.
  • Empirical antibiotic guidance is available in the unit and on wards.

Control gaps

Fever advice is given once at the start of treatment and is not reinforced at each visit.

Additional controls

  • Prevent: Give each patient a fever card and a phone line staffed around the clock during treatment.
  • Respond: Start the sepsis pathway and the first antibiotic dose within the target time set by the consultant.
Likelihood 4 x impact 5 before; 3 x 4 after Owner: Consultant hematologist Target: Within 30 days Early warning: Patients with a temperature above the set threshold and a low white cell count not seen within the target time.
H03

Bleeding or thrombosis from low platelets or anticoagulation

Safety Before 12 After 6

Low platelets, anticoagulant doses or antiplatelet drugs cause bleeding, or clots form in patients with central lines or reduced mobility, and the change is missed until harm occurs.

Who or what is affected: Patients with bleeding risk, ward staff and families

Causes

Chemotherapy suppression, interacting medicines, reduced mobility and central venous catheters.

Consequences

Major bleeding, emergency transfusion, deep vein thrombosis, pulmonary embolism and prolonged stay.

Existing controls

  • Platelet thresholds for transfusion are written in the local protocol.
  • Anticoagulant doses are checked against recent laboratory results.

Control gaps

Bleeding scores are not repeated after a change in medicines or counts.

Additional controls

  • Detect: Review platelet counts and bleeding scores at each ward round and record the plan.
  • Prevent: Hold a daily check of anticoagulant and antiplatelet orders against the latest counts.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Clinical nurse specialist for hematology Target: Within 60 days Early warning: A patient whose platelet count falls below the protocol threshold without a documented review within the shift.
H04

Wrong blood product or transfusion reaction

Safety Before 10 After 5

A blood product is issued for the wrong patient, the sample is mislabeled, or a transfusion reaction is not recognized and stopped early, causing hemolysis or other serious harm.

Who or what is affected: Patients receiving transfusions, transfusion staff and nurses

Causes

Mislabeled samples, busy periods and unfamiliar patients on the ward.

Consequences

Hemolytic reaction, organ damage, serious harm and incident investigation.

Existing controls

  • Patient identity and sample labels are checked at the bedside before issue.
  • Reactions are recorded and the transfusion lead reviews them monthly.

Control gaps

Bedside checks are not always done against the issue record, and reaction recognition varies between shifts.

Additional controls

  • Prevent: Use electronic bedside identity checks linked to the blood issue record for every unit.
  • Respond: Train all administering staff in the reaction protocol with stop, check and call steps.
Likelihood 2 x impact 5 before; 1 x 5 after Owner: Transfusion lead Target: Within 45 days Early warning: Blood product issues where the identity check is incomplete or a sample has been relabeled.
H05

Hazardous drug exposure and sharps injury for staff

Safety Before 9 After 4

Staff prepare, give or clean up cytotoxic drugs without the right equipment, or a needle or sharp injures a clinician, exposing them to hazardous drug residues or blood-borne infection.

Who or what is affected: Pharmacy technicians, nurses, cleaners and medical staff

Causes

Rushed preparation, damaged safety cabinets and needles recapped at the chair.

Consequences

Staff health effects, sickness absence, claims and loss of confidence in the unit.

Existing controls

  • Preparation takes place in a safety cabinet with trained staff.
  • Sharps bins are placed at each treatment chair.

Control gaps

Wipe test results are not reviewed and exposure reports are under-recorded.

Additional controls

  • Prevent: Use closed system transfer devices for every hazardous drug and check gloves and gowns at each step.
  • Respond: Provide an immediate exposure response with occupational health review within 24 hours.
Likelihood 3 x impact 3 before; 2 x 2 after Owner: Occupational health lead Target: Within 60 days Early warning: Staff exposure reports for hazardous drugs or needle stick injuries each month.
H06

Consent, record and privacy failures

Legal and compliance Before 12 After 6

Consent for treatment or research is not recorded or is out of date, or diagnosis and treatment records are viewed or shared without need, so a patient's rights and privacy are breached.

Who or what is affected: Patients, families, clinicians and records staff

Causes

Busy clinics, forms completed late and wide access rights for rotating staff.

Consequences

Complaints, regulator notice, loss of trust and possible legal action in the relevant jurisdiction.

Existing controls

  • Written consent forms are signed before each new treatment type.
  • Access to electronic records requires a named login with a role.

Control gaps

Consent is checked at the start of treatment only, and access logs are not reviewed.

Additional controls

  • Detect: Audit a sample of consent forms and record access logs each quarter.
  • Prevent: Add a consent expiry check to the treatment plan and block orders where consent is missing.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Information governance lead Target: Within 60 days Early warning: Treatment orders with no current consent recorded, or repeated access to records by staff without a clinical link.
H07

Handover gaps and competence of cover staff

People Before 12 After 6

Key information about treatment plans, allergies or warning signs is lost at shift change or transfer, or staff without current competence in oncology care are assigned to complex patients.

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

Causes

Short staffing, agency or bank cover and handovers given at the desk or in corridors.

Consequences

Missed doses, delayed escalation, avoidable deterioration and complaints.

Existing controls

  • Shift handover happens at the bedside for high-risk patients.
  • Competency records are kept for chemotherapy administration.

Control gaps

Structured handover is used on some wards only, and competency checks are not linked to rota planning.

Additional controls

  • Prevent: Use a structured handover tool with treatment, allergy and warning sign fields completed for every transfer.
  • Detect: Check competency records against the rota each week and flag gaps to the ward manager.
Likelihood 4 x impact 3 before; 2 x 3 after Owner: Ward manager Target: Within 60 days Early warning: More than one in ten sampled handovers missing a key clinical item.
H08

Laboratory, record system or equipment downtime

Technology and data Before 12 After 6

The laboratory system, electronic record, infusion pumps or refrigerators fail, so blood results, orders and drug storage cannot be trusted and treatment is delayed or made unsafe.

Who or what is affected: Patients, clinicians, laboratory staff and pharmacists

Causes

Software faults, power cuts, ageing equipment and unplanned system upgrades.

Consequences

Delayed treatment, wrong results, unsafe drug storage and harm to patients.

Existing controls

  • Infusion pumps are serviced on a set schedule.
  • Refrigerators for drugs and blood have temperature alarms.

Control gaps

The downtime plan has not been tested end to end, and temperature alarms go to one shared mailbox.

Additional controls

  • Recover: Test a paper downtime plan for orders and results twice a year and keep copies on each ward.
  • Respond: Hold a standby pump and cold storage plan with a named contact for failures.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Digital services lead Target: Within 60 days Early warning: Repeated temperature alarms or system outages that run longer than the agreed recovery time.

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, with harm to patients weighted most heavily. Multiplying the two gives a score from 1 to 25, which falls into one of four bands: Low from 1 to 4, Medium from 5 to 9, High from 10 to 16 and Critical from 17 to 25. Inherent risk is the score before controls, and residual risk is the score after existing and additional controls are in place. Residual must never be higher than inherent, and any inherent score of 10 or more needs a clear reduction. Critical and High risks need a named owner, a dated plan and review by the clinical governance group. Medium risks need routine controls with a named owner, and Low risks are accepted and watched. Ratings are challenged in a structured way: frontline nurses, pharmacists and patients or carers are asked whether the score matches what they see, and any disagreement is recorded and taken to the next review. Any harm or near miss triggers an immediate rescore. Ratings are a guide for ordering work, not a measurement, and specialist clinical review is needed before any score changes practice.

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 temperature above the set threshold and a low white cell count not seen within the target time.Escalate to the consultant on call at once, and to the clinical governance lead if the target is missed twice in a month.
Chemotherapy orders released without a documented independent double check.Escalate to the chief pharmacist the same day, and hold the order until the check is complete.
Blood product issues where the identity check is incomplete or a sample has been relabeled.Escalate to the transfusion lead at once, and stop issue until the sample identity is confirmed.
Staff exposure reports for hazardous drugs or needle stick injuries each month.Escalate to the occupational health lead within 24 hours, and to the ward manager if the count rises for two months.
Handover records missing key clinical items in a sampled audit.Escalate to the ward manager when more than one in ten sampled handovers is incomplete, and to the clinical governance lead after a second audit.

Contingency arrangements

If a serious event occurs, such as a patient with fever and low white cells who deteriorates, a wrong blood transfusion or a major medicine error, the duty clinician starts the local emergency and sepsis pathway at once and informs the consultant on call. The ward or unit stops related infusions and preserves the records and blood bags. The clinical lead informs the patient and family openly, reports the event through the incident system, and notifies regulators and professional bodies as required in the relevant jurisdiction. The laboratory and pharmacy support a recheck of affected results, and the service keeps a standby plan for beds, staff and drug supply.

Prioritized action plan

  1. Introduce a fever and neutropenia pathway with a time target for clinical review, owner consultant hematologist, within 30 days.
  2. Require independent double checks for high-alert chemotherapy and electronic identity checks for blood products, owner chief pharmacist, within 45 days.
  3. Set a written handover standard using a structured tool for every transfer of patient care, owner ward manager, within 60 days.
  4. Test the downtime plan for the electronic record and laboratory system end to end, owner digital services lead, within 60 days.
  5. Create a consent and records audit with a named reviewer each quarter, owner information governance lead, within 90 days.

Conclusion

Safe hematology and oncology care depends on a few steady habits: double checks for high-risk medicines, a fast fever pathway for patients with low white cells, correct identity checks for blood products, safe handling of hazardous drugs, complete consent and records, and clear handovers. The highest scores sit with neutropenic sepsis and dosing errors, and each has controls that bring the residual score down. Treat the register as a living record, review it on the stated cycle, and seek specialist clinical advice for any real treatment or service decision.

Assumptions and limitations

Assumptions

  • The service follows local clinical protocols for each treatment regimen, and jurisdiction is not specified, so legal duties are described in general terms.
  • Staff are licensed professionals with current competency records, working on managed equipment and electronic records.
  • Patients are adults, and children are treated in a separate pediatric service not covered here.

Limitations

  • The scores are examples for learning and do not describe any real service or patient group.
  • Clinical guidance changes over time, so specialist and licensed clinical review is needed before any change to practice.
  • This is educational content and does not replace a formal site-specific risk assessment or clinical governance review.

Related frameworks to study

  • Hierarchy of controls
  • Clinical risk management cycle
  • Structured handover tool such as SBAR
  • Incident reporting and learning 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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