Risk Assessment in Hospital

Security
Ref Risk Impact Affected Likelihood of Magnitude Rank Proactive Mitigation Active Responsibility due date review status remarks Likelihood of Magnitude Rank
Department Occurrence of Impact Mitigation date Occurrence of Impact
inspection
Monitoring Cameras and
are installed allover the investigation
Patients’ affect the hospital and in the s are done Security
S1 belongings hospital All Hospital 3 3 9 corridors and in and police department
could be stolen. repution
opposite of patients station
rooms reporting if
needed
Any of the affect the Monitoring Cameras Security

hospital are installed allover the
S2 premises could hospital All Hospital 3 5 15 hospital and alarm department
repution
be assaulted. systems on the gates
Financial loss
The received Potential Monitoring Cameras stores &
S3 goods could not unavailability All Hospital 5 3 15 are installed infront of police station security
be of service the stores and alarm reporting departments
secured/stolen. provided by systems on the gates
the hospital
loss any followup of the Engineering

break down in valuable preventive Department
S4 the surveillance items or All Hospital 2 3 6 maintenance of the is reported Engineering
cameras/electri to take the Department
city cut off. valunerable cameras and prooper
patient harm monitoring system
action
the
The possibility financial loss an assets log book is responsible
of not tracing to the created and follow up department
an asset that hospital& of the assets is done Department
S5 has been issued may affect All Hospital 1 3 3 and monthly report is will be that own the
for the service done to follow up with informed to Asset
maintenance/ot provide to the departments own taje the
hers. the patients the asset approprite
action
Adminstrative Support
Affected Likelihood of Magnitude review Likelihood of Magnitude

Ref Risk Impact Department Occurrence of Impact Rank Proactive Mitigation Active Mitigation Responsibility due date date status remarks Occurrence of Impact Rank
1. Wasting time to
sending all order or
sending by mistakes Admin -Call on call staff
High 2. Some mistakes in support- -Training & education -Supervisor will caver the
the charging and may -Availability of on call staff in case of shortage
AS 1 turnover/employees be lost money Auditing-Lab- 3 3 9 emergency -One of the staff handle more H.R
number shrinkage. 3. Can’t give the Rad-Dietition than one unit
annual vacations for and finance
the old staff
Delay in all process &

we can’t do the
following items :1.
sending any orders or
discharge the patients
2. registration the
data of the new -Work manual to enter the
data
admission -Training how to enter data manual -communicate with other
AS 2 System outage. 3. transfer the All 2 4 12 -IT preventive maintenance to the department to follow up the IT
patients through the Departments system pending orders or to insert
system some orders
4. looking for the
patients data
5. charging the
supplies or pharmacy
and finance can’t
prepare the bill.
1. Can’t reach the

department target checkup - -Marketing for checkup Programs Incentives for the staff to
AS 3 Decrease in medical 2. Decrease the finance- 2 3 6 -Making new contact with the encourage patient to use the Marketing
check-ups cases. revenue of the business companies service
hospital development
1. We can’t restore
the history of the
patients ( medical
data – like or dislike -Call IT to give support
food – personal data ) -IT Maintenance -Ask relatives to bring any old
AS 4 Loss of data stored on 2. The finance All 1 4 4 -IT backup investigations IT
the system. department can’t Departments -Use information in patient file -Use the medical file to
prepare accurate bill retrieve the results
3. Losing all
appointment of the
patients
Retaliation from the 1. The patient will be -No blame culture encouraged -No blame culture
complaining worry and will not - Education for the staff that we are encouraged
AS 5 department against complained All 2 4 8 looking for system faults not person - Education for the staff that COO
the patient or his 2. Decrease the level Departments faults we are looking for system
relatives or even the of service faults not person faults
Public relations staff.
-Confirmation of data given by ID -Correction of faults

Receiving falsified Losing the employees All services -Check system to ensure that the information Front registration
AS 6 information from time departments 3 2 6 patient didn’t had data office
patients.
1. We Can’t finishing
Sample error as a the final report of the
result of calling only patients All medical -Sample size identified -Increase the sample to Head of public
AS 7 50% of the discharged 2. We Can’t complete dep.-Medical 3 3 9 -Ensure complain of sample monthly complete with the sample relations
patients. the Checkup program Recrds size
of the patients
No-show cases from -Call the patient to know the

either Doctors or Cause of no show
AS 8 patients (in full Losing the patients Check up - All 2 3 6 -Confirmation with patient one day -Increase the walk in Head of Check up
medical checkup time & satisfaction medical dep. before -Stop service programs
programs).
1. The relative cant
access the patent’s
room
2. We can’t contact
any sponsors -Coordination with the OPD before
Crowded clinics could companies for the the patient visit -Rescheduling the clinics to Head of Check up
AS 9 delay the medical patients Check up 3 3 9 -Handling with OPD to give priority to
checkup progress. 3. Cant contact the check up start with less crowded one programs
vendors
4. losing time and
effort of patient's and
employees
1.Missing -Use overhead

Computer Communications All Preventive maintenance by IT & -Mobile
AS 10 &Telephone failure 2.Delay in the process Departments 3 2 6 maintenance department -Manual System IT
Biomedical Engineering
Ref Risk Impact Affected Likelihood of Magnitude of Rank Proactive Active Mitigation Responsibility due date review status remarks Likelihood of Magnitude of Rank
Department Occurrence Impact Mitigation date Occurrence Impact
* Ventilators
Shortage in O2 at O2 of 21%
Supply only. * Find an * Provide Backup
BE 1 All Hospital 3 4 12 alternative BME
(Factory Anesthsia supplier. O2 Cylinders.
Outage) Will not be
available.
Unavailability * Partial/ * Provide stock * Find alternative /

BE 2 of some spare complete All Hospital 3 4 12 of main spare compatible spare BME, Purchasing
parts. Loss of parts. parts.
functionality.
BE 3 Electricity cut * Complete

Loss of All Hospital 3 4 12
* Replace UPS
batteries as
* Provide UPS
supply for critical BME, Maintenance
off. functionality. recommended. areas.
Inability to
maintain the * * Make the * Start interviews
BE 4 needed Inadequate BME 3 3 9 team feel and hire people. BME, HR
Manpower Performance. satisfied.
(Staff Backup)
Increasing the
maintenance * Delay of * Put limits on
Contracts fees such situations * Neogotiate
BE 5 due to contract BME, Finance 2 2 4 when signing Prices. BME, Finance
increase in the renewals. new contracts.
Exchange rates
Water supply Dialysis and Ensure Tanks Stop Unesseacary

BE 6 Cut off Lab will be Lab, Dialysis 3 3 9 are full water usage Maintenance
out of service
Inability to
provide the
needed Inability to * Provide stock Find a substitute in
BE 7 technical make repairs All Hospital 3 3 9 of main spare the local market. BME
support for parts.
the devices
inside Egypt.
Inadequate make an annual

BE8 Obsolescence device All Hospital 3 3 9 Assess devices Renovation plan BME, High
of the devices. performance on regular basis and put a Budget Management
for it.
Failing to
provide the
needed Increase # of
BE 9 preventive device All Hospital 4 2 8 Establish PM Perform PM BME
maintenance failures Procedures Immediately
for the
medical
equipments
Consuming a
lot of time for
fixing medical Increase # of Make decisins Find an alternative
BE 10 equipments, device All Hospital 3 3 9 with a known device to do the BME
might delay failures time frame job
other
department.
Failing to
comply with
Increase # of
BE 11 the medical device All Hospital 4 2 8 Make a realistic Perform PM BME
equipments failures Plan Immediately
calibration
plan.
Negative on
patient
BE 12 Wall Oxygen requiring O2 All Hospital 3 4 12 Adequate Find Alternative BME
supply failure Maintenance Source
(Vent and
Anesthsia)
Failure of non- Negative Adequate

invasive Blood impact on Maintenance Fix monitor and
BE 13 Pressure ICU, CCU and ICU, CCU, OR 3 2 6 and transducer replace old cables BME, Purchase
monitors OR patients availability
Failure of ECG
Lack of
BE 14 Machine & patient All Hospital 3 2 6 PM Plan Purchase new BME, Purchasing
Pulse adherence equipment, repair
oximeters monitoring
Failure of
BE 15 infusionPumps Lack of drug All Hospital 1 4 4 PM Plan Purchase new BME, Purchasing
/Syringe delivery adherence equipment, repair
Drivers
Reagents and PM Plan Purchase new

BE 16 Refrigeration drugs Lab, Pharmacy 3 3 9 adherence equipment, repair BME, Purchasing
damage.
Inadequate Continuous
monitoring,
BE 17 Staffing service All Hospital 3 4 12 evaluation and Recruite new staff BME
delivery appraisals
Failure of Shortage of
inpatient Immediate
BE 18 electric beds hospital All Hospital 1 4 4 Regular PM repairs/Purchases BME, Purchase
capacity
machines
Cannot save
BE 19 Failure of patients with All Hospital 3 4 12 Regular PM Immediate BME, Purchase
Defibrillator arrest repairs/Purchases
Failure of No dialysis Immediate
BE 20 Dialysis service Dialysis 2 4 8 Regular PM repairs/Purchases BME, Purchase
machines provided
Failure of foot Patients will ICU, CCU, Immediate

BE 21 compression not receive 3 2 6 Regular PM BME, Purchase
devices such therapy Inpatient repairs/Purchases
Failure of
Central Lack of Immediate
BE 22 Monitoring central ICU, CCU 2 2 4 Regular PM BME, Purchase
System monitoring repairs/Purchases
Cannot
BE 23 Failure of receive ICU, CCU 2 5 10 Regular PM Immediate BME, Purchase
ventilators patients in repairs/Purchases
the ICU/CCU
Failure of Cannot OR, Endo, ER, Immediate

BE 24 anesthesia perform 2 5 10 Regular PM BME, Purchase
machines procedures Rad repairs/Purchases
Failure of Cannot
BE 25 laparoscopic perform OR 3 3 9 Regular PM Immediate BME, Purchase
repairs/Purchases
System laparscopy
Failure of Cannot Immediate

BE 26 diathermy perform OR, Endo 3 4 12 Regular PM repairs/Purchases BME, Purchase
machines procedures
Failure of Cannot Immediate

BE 27 operating perform OR 3 3 9 Regular PM repairs/Purchases BME, Purchase
tables procedures
Negative on
Wall suction patients Adequate Use Portable
BE 28 All Hospital 2 2 4 Maintenance BME, All units
failure requiring and PM Suction
fluid suction
Cannot
Failure of perform Adequate Immediate
BE 29 Endo 3 3 9 Maintenance BME, Purchase, Endo
Endoscopies endo and PM repairs/Purchases
procedures
Cannot
Failure of sterilize Adequate Immediate
BE 30 CSSD, All hospital 3 4 12 Maintenance BME, Purchase
sterilizing necessary and PM repairs/Purchases
tools
Adequate
BE 31 MRI Quench Cannot make
MR imaging Rad 4 2 8 Maintenance Immediate repairs BME
and PM
Engineering Department
Ref Risk Impact Affected Likelihood of Magnitude Rank Proactive Active Mitigation Responsibility due date review status remarks Likelihood of Magnitude Rank
The hospital had 2 water tanks

Failure of Stoppage of main Two water worked as backup in case of external
water external main water supply failure
ED 1 External main source& staring of All Hospital 2 5 10 tank with ful -Water supply the critical area only Engineering
water supply outage of water capcity 700 - contact with the water company to Department
less than 24 m2.
tannk bring the truck when one tank is
empty
contract with
water
company -
testing of Water vehicles from the national
Failure of water water company acts as back up then
ED 2 External main outage of thea All Hospital 2 5 10 availblity& The ER director uses the referral Engineering
water supply water estimation of system according to WHO if there is a Department
more than24 duration time disaster in water supply
to empty the
tank done
quarterly
contract with
water
company
-
testing of
External water water The ER director uses the referral
ED 3 outage for faliure of external All Hospital 1 5 5 availblity& system according to WHO if there is a Engineering
more than 3 water supply Department
days. estimation of disaster in water supply
duration time
to empty the
tank done
quarterly
continouse
water analysis
biological
monthly&
chemical The external Water supply
Pollution of
ED 4 external water poisoning of staff& All Hospital 1 5 5 quarterly Is disconnected and the hospital Engineering
patients presnse of water tanks are used Department
supply water valves to
allow shut off
water to avoid
dissemnation
of pollution
Pollution of poisoning of staff& The tanks were disconnected from

water tank is the system and the external source Engineering
ED 5 internal water employees All Hospital 1 5 5 secured. will be used directly until cleaning the Department
supply tanks
High pressure stoppage of water continouse There are four water pump that act Engineering
ED 6 water pump All Hospital 3 4 12
failure supply maintenance automatically in case of one failure Department
The other The other branch will automatically

branch will entered by coupler unit within 7
Electrical The electrical main automatically seconds -The generator Engineering
ED 7 All Hospital 3 4 12 entered by will operate within 7 seconds to
faliure line is disconected coupler unit cover the criitical branch emergency Department
within 7 linethe emergency line will supply
seconds the critical area
new building, continouse The critical department as the OR,

ED 8 Generator failure of critical ICUs, OR, 1 4 4 maintenance& ICU, LAB, CCU will be loaded on the Engineering
falure branch PACU testing every U.P.S units. hospital will work on Department
quarter
The critical department as the OR,

ICU, LAB, CCU will be loaded on the
continouse U.P.S units.
Fuel tank failure of critical new building, monitoring of Main tank will supply the generator Engineering
ED 9 outage branch ICUs, OR, 1 5 5 tank the solar tank. Department
PACU totakl tank Calling the the environmental
capicy 65.000l company to support the hospital with
solar
Automatic The critical department as the OR,

ED 10 ransfer swich failure of generator All Hospital 3 4 12 Continouse ICU, LAB, CCU will be loaded on the Engineering
maintenance Department
failure U.P.S units. hospital will work on
Boiler system
ED 11 fuel failure stopage of hot line laundry, CSSD 2 5 10 Boiler Calling the NAT Gas company to Engineering
(natural gas) supply & the hospital maintenance support the hospital with natural gas Department
HEPA filter is
used in OR
-
Air handling contamination of air Continouse Engineering
ED 12 unit supply of the All Hospital 1 4 4 maintenance contact the company Department
contmination hospital to pre-back
filter -
Sample of air
taken.
Periodic Stop the admission of patient in this

Negative stopage of postive& OR, ICU,BMT, maintenace& rooms. Patients in Engineering
ED 13 pressure/Posti negtive rooms 1 3 3 monitoring of negative room pressure will wear
ve pressure presure ER pressure mask N95 till trans fer the patient to Department
rooms anther hospitl
fire safety
Ref Risk Impact Affected Likelihood of Magnitude Rank Proactive Mitigation Active Mitigation Responsibility due date review status remarks Likelihood of Magnitude Rank
Department Occurrence of Impact date Occurrence of Impact
The firefighting
financial loss Automatic smoke& fire damper. systme will be
injury& The ventilation will be stopped in activated The
Presence of anesthetic harm to staff, Operatin case of fire. The doors doors Head of
FS 1 gases& equipment which 1 5 5 automatically closed & fire zone occupational
act source of fire patients & room completely separated. automatically safety
visitors from Continouse maintenance to closed & fire zone
fire firefighting system completely
separated.
storage of flamable items& financial loss Smoke detector. fire The firefighting Head of
FS 2 hazardouse chemical which injury& Internal store 2 5 10 extinguishers: chemical powder, systme will be occupational
source of fire harm to staff& carbon dioxide co2 Hose reel activated safety
visitors Water Sprinkle.
financial loss
storage of flamable items& injury& Fire extiguisher:chemical powder& Head of Head of
FS 3 hazardouse chemical which harm to staff, Outside stores 2 5 10 automatic extiguisher occupational occupational
source of fire patients & safety safety
visitors
financial loss
injury&
harm to staff, Fire extiguisher:CO2& automatic The firefighting Head of
FS 4 fire in the medical record patients & Medical 1 5 5 extiguisher Smoke detectors systme will be occupational
visitors records fire hose reel activated safety
loss of patient
data
Fire extiguisher:Chemical&
automatic extiguisher
Smoke& heat detectors fire
grease using& producing financial loss hose reel, blanket, hose reel. The firefighting Head of
FS 5 machines natural gase line injury& harm kitchen& 3 5 15 Grease filter above the grease systme will be occupational Jan.017 Jan.017 done 1 5 5
which act as source of fire to staff, & cafeteria producing. Any activated safety
visitors remenant of oil cleaned & regular
cleaning of hood done
financial loss
electrical spark& flamable injury& Generator& Fire extiguisher:Chemical& The firefighting Head of
FS 6 electrical 1 5 5 systme will be occupational
solar as source fire harm to staff, automatic extiguisher
& visitors panel activated safety
financial loss
electrical sparks from injury& Laundry, Fire extiguisher:Chemical powder The firefighting Head of
FS 7 equipment produce source harm to staff, chillers, 2 5 10 systme will be occupational
Smoke detectors
of fire & visitors boilers activated safety
financial loss The firefighting Head of
FS 8 electrical spark transformed injury& Transformers 1 5 5 Fire extiguisher:CO2 system Smoke systme will be occupational
into fire harm to staff, detectors activated safety
& visitors
LAB,
financial loss Radiology,
equipment which may act injury& radiotherapy, Fire extiguisher:CO2 system Smoke The firefighting Head of
FS 9 as source of fire& 1 5 5 systme will be occupational
harm to staff, CSSD, detectors
connected to electricty & visitors Oncology day activated safety
case
when alarm
activated the
charge nurse will
financial loss Medical gases valves present in be responsble to
explosion of medical gase& injury& In regular unit each unit charge shut off the nursing, safety&
FS 10 presensice of flamable 2 5 10 medical
harm to staff, nurse is trained to shut off the medical gases if
gases & visitors medical valves not avilable the technology
safety officer or
biomedical will be
responsble.
Continouse education aboUt code presence of

increase the red& RACE& PASS action disaster comander
lack of awarness of staff numbers of cards of role of staff distributed to arrange the
FS 11 about how to deal in case human& all hospital 2 5 10 presence of material roles action Safety officer
of presence of fire financial loss in distributed to staff fire cards will be
case of fire drill conducted twice annualy distributed to the
responsble staff
smoke detectors
Smoking not allowed inside the will be activated&
hospital outside places designated firefighting system
FS 12 Smoking inside the hospital source of fire all hospital 4 5 20 the security will Safety officer Jan.017 Jan.017 done 1 5 5
for smoking no smoking signs
availble identify the area&
contact the
assigned personel
financial loss kitchen The natural gase line connected to the responsble
FS 13 explosuion of natural gase injury& main natural 2 5 10 gieger which automaticly shut off staff will shut off maintenance&
line harm to staff, gas pipe line incase of oncrease of pressure the valves safety
& visitors boilers
financial loss& The main tank under the earth the fire fighting& maintenance&
FS 14 fire in the main disel tank explosusion of main tank 1 5 5 exhust system foam cabinet extigusher will safety
main tank work
financial loss& the fire fighting&
FS 15 fire in the diesel tank explosusion of generator 1 5 5 fire alaram& smoke detectors extigusher will maintenance&
main tank foam manuual extiguishers work safety
FOOD & BEVERAGE
Affected Likelihood of Magnitude of Likelihood of Magnitude of

Ref Risk Impact Department Occurrence Impact Rank Proactive Mitigation Active Mitigation Responsibility due date review date status remarks Occurrence Impact Rank
Kitchen , Manual washing room

Stopping of Kafeteria, avilible. Dish wash
FB 1 Electricity outage Dish washer, Inpatient, 3 3 9 detergent to be used washing the dishes food & beverage dep.
for long period Mixer & Employees & manul avilible. Stock manually
Fridge. Visitors. and clear dishes avilbile
staff Injury, education to staff about

Sick leave, Kitchen , safety issue. Wearing medical advice given.
Work injuries and Decrease of Kafeteria, and PPE personal According to the food & beverage dep.,safety
FB 2 infection. staff available Inpatient, 3 4 12 protective equipment. medical condition the dep, medical council
in work load Employees & Traing of staff how to investigations treatment
times. Visitors. prepare food in safeway are for free.
Kitchen ,
Kafeteria, providing cold meals
FB 3 Gas Outage All kitchen Hot Inpatient, 1 5 5 Continoue maintence by and meals which didn't food & beverage
lines. Employees & nat gas company done need cooking hot line dep.,maintainence dep.
Visitors.
Kitchen ,
Traing of staff.
Misuse of increase the Kafeteria, Education. Inspection
FB 4 available materials cost of the Inpatient, 1 2 2 dine by material food & beverage dep.
(raw material). meals. Employees & mangement
Visitors.
Delay in repairing
the kitchen Kitchen , review the process of contact maintainence
equipments and stop working Kafeteria, regular maintainence for fixation use food and beverage &
FB 5 increasing the of the dish Inpatient, 5 3 15 and temperature disposable utensils and maintenance departments Nov.016 Jan 017 done 2 2 4
maintenance cost washer Employees & monitoring by kitchen manual washing
of the dish washer Visitors. staff (Mr. Ahmad Ali)
Kitchen , work to stop in both
increasing the
maintenance cost stop working Kafeteria, no disposal of oils or any kitchen and cafeteria food and beverage &
FB 6 of the sewege of the sewege Inpatient, 5 4 20 item that may produce and contact maintenance departments Nov.016 Dec.016 done 1 4 4
Disposal Disposal Employees & sewege obstruction maintainence for
Visitors. fixation
Kitchen , developing guidelines

unsafe process of Kafeteria, for safe food inservice training and food and beverage
FB 7 preparing and food poisoning Inpatient, 4 4 16 preparation and enforcing guidelines department Apr.017 May.017 not done DONE in Oct.017 2 3 8
storing food Employees & education of the kitchen implementation
Visitors. staff
General Accounting & Financial
Ref Risk Impact Affected Likelihood of Magnitude of Rank Proactive Mitigation Active Mitigation Responsibility due date review status remarks Likelihood of Magnitude of Rank
Department Occurrence Impact date Occurrence Impact
Quickly handle errors &

GA 1 Invalid changes are made to the financial Negative impact on business
closing and reporting process. results & decisions making Finance 1 3 3 accuretly closing check audit the results before
sending to top Finance
management .
Internal and external financial reporting Preparing financial reports

requirements and deadlines are not Unsatisfaction of top on appropriate time & send to the top
management and steck
GA 2 identified, updated, and communicated management and steck Finance 2 3 6 Update the share holder holder updated financial Finance
on a timely basis and in the appropriate holders. every quarter by financial results .
accounting period. results
Roles and responsibilities in the financial

reporting process are not clearly defined,
documented, updated, and Delay in the discovery of Determine responsibilities correct immediately &
GA 3 communicated to appropriate errors and solving its negative All 1 2 2 and its process & audit on reflect the impact on Finance
departments and individuals on a timely effect the monthly bases for all finanical statement
basis and in the appropriate accounting financial transaction
period.
Reviewing data before

disclosure & keeping the correct immediately &
GA 4 Information is not identified or captured Lack of credibility All 2 3 6 top management on touch reflect the impact on All
correctly.
with the performance on finanical statement
daily and weekly basis
Reviewing data before

Misstatement of the financial statements disclosure & keeping the correct immediately &
GA 5 due to clerical errors and/or omission of Fake number will effect on Finance 1 2 2 reflect the impact on
top management on touch finanical Finance
descion making statement or in
entries. with the performance on repoting
daily and weekly basis
Inaccurate processing of daily Monthly closing in Notify the financial dep Applaying the Adjustment
GA 6 transactions and journal entries could appropriate time Finance 2 3 6 and commitment to the entries with the same Finance
occur. monthly close date period with limitation
Errors in the reconciliation process Reviewing all the report

GA 7 remain undetected. General ledger
account balance may be misstated (not All reports will be not correct Finance 3 3 9 before displaying it to the correct immediately IT & Finance
reflected in the sub-ledger). top management
Calculations or estimations made are Unacceptable data for negotiae with uditor and
GA 8 based on unreasonable assumptions or internal or external data Finance 2 2 4 correct with right data correct with right data Finance
methods.
Financial assets and liabilities may be observation on daily basis

GA 9 over- or understated. Liquidity & decisions making All 1 4 4 cash postion take immediately action Finance
Accounts payables or accounts Wrong reports and liquidity observation on daily basis
GA 10 receivables may be over- or understated ratio effect on decisions Finance 2 4 8 cash postion take immediately action Finance
making
Significant estimates or judgments are wasting time for other Determine process cycle take immediately action
performed by employees not having
GA 11 received the most current information or employees to approve wrong Finance 1 3 3 with related departments and correct with a right Finance
judgments and related employee cycle
incomplete information.
Key decisions are based on Wrong decisions with Supporting decisions with
GA 12 incorrect/outdated information resulting negative effect on the All 1 4 4 financial results and their Finance
in erroneous financial statements. company impact on the company
estabilish procedure and

GA 13 Closing activities and procedures are not Reports not accurate not Finance 2 3 6 policies for all activities in Finance
established. follow policies organisation to track its
going on the right way
GA 14 Consolidation entries are recorded Reports not accurate finance/ 1 4 4 Record all entries Finance
incompletely and inconsistently. stakeholder accurately on time
Consolidated financial statements do not Reports not accurate / data finance/ Record all entries
GA 15 include all accounts of all consolidated 1 4 4 Finance
subsidiaries. not reliable. stakeholder accurately on time
Erroneous data is incorporated in the Reports not accurate / data finance/ Record all entries
GA 16 consolidated financial statement. not reliable. stakeholder 2 3 6 accurately on time Finance
In translation the subsidiaries financial

statements into the holdings reporting Reports not accurate / data Record all entries
GA 17 currency erroneous foreign exchange not reliable. Finance/All 1 3 3 accurately on time Finance
rates are used.
GA 18 Subsequent changes occur after closed Adjustment on ended Finance 2 3 6 Quickly handle errors Finance
accounting period. financial statements
put policies and procedure

GA 19 Negotiated obligations and covenants are
not known to accounting. taking Decison all 2 3 6 that appropriate all
obligations
Bank accounts and responsibilities are

GA 20 not appropriately established resulting in fraud in bank responsibility finance 1 4 4 separation on finance
fraud issues. responsibility
Treasury Process
Bank accounts and responsibilities are

T1 not appropriately established resulting in fraud in bank responsibility finance 1 4 4 segregation of duties finance
fraud issues.
An employee may have the ability to

initiate authorize and record a
transaction or may have custody of assets
T2 within the process such that they are able Data not accurate finance 1 4 4 segregation of duties finance
both to perpetrate and conceal an error
or irregularity.
T3 No proper segregation of duties in cash fraud in treasury finance 1 3 3 separation on finance

handling process. responsibility
Assets and liabilities denominated in not accurate financial

T4 foreign currencies may be overstated or statement and bussiness finance/all 2 4 8 make sure use accurate finance
understated (Incorrect exchange rate is exchange rate
used). report
T5 Buying counterfit foreign currencies from fraud in organization finance/all 4 4 16 only provide cash from the finance Jan.017 jan.017 done 1 4 4
the black market. legal market
Exchange risk exposure is not fraud in all activities in The importance of taking
T6 appropriately mitigated. organization all 2 4 8 into consideration finance
exchange rate change
The Hospital may not be able to meet its The inability to meet the
T7 cash requirements appropriately. needs of all departments finance 2 4 8 make cash flow monthely finance
Failure to making available the foreign The inability to meet the making available the
T8 currencies required to timely pay the finance 3 3 9 foreign currencies in finance
Hospital’s liabilities. needs of all departments appropriate time
The Hospital may not account

T9 appropriately for loan / debt instrument fraud in organization all 1 4 4 Follow up all obligation finance
transactions, e.g., entering new loans, due to organization
debt payments, retirement of debts etc.
The company may not comply with
obligations and covenants resulting in Follow up all obligation
T 10 penalties, acceleration of debt fraud in organization all 1 4 4 due to organization finance
repayment and legal or regulatory issues.
As a result, liabilities may be understated.
Large cash amounts are not handled

T 11 appropriately (Improper investing investing decision finance/ 2 4 8 good investment finance
stakeholder
decisions)
Patients Accounts
Providing medical services to patients Patient accounts

PA 1 without reference letters and prior Unpaid amount and Acr 3 4 12
approvals
Improper monitoring for the patients

PA 2 balances. Unpaid amount Patient accounts 2 3 6
PA 3 Issuing patients invoices that does not Unpaid amount Patient accounts 3 3 9
match with the medical reports and Acr
PA 4 System breakdown or slow response Negative hospital image All 2 4 8
PA 5 High staff Turn Over Missing the experince Patient accounts 3 3 9
Budgeting and Financial analysis Process
Not all factors/elements taken into take into consideration all

BA 1 consideration during the budget Decision making all 2 2 4 factor during preparation finance
preparation. budget
Budget is not aligned with the Hospital's Supporting decisions with

objectives and strategies due to wrong Decision making for all finance/
BA 2 allocation of resources between investor and stakeholder stakeholder 1 4 4 financial results and their finance
functions. impact on the company
Unreliable and inaccurate reports Decision making top finance/ review accurately all data
BA 3 management and 2 3 6 during vs . Actual and finance
showing actual results vs. budget. stakeholder stakeholder budget
staff retention plan, immediate interview with

BA 4 High staff Turn Over Missing the experince finance 5 3 15 increase staff moral, hire the staff to prevent HR Apr.017 Apr.017 done 4 3 12
experienced staff resignation
Costing Process
C1 High staff turnover Missing the experince Costing 3 4 12 Continuous training and HR
Department/all
learning for staff
C2 Using invalid data, leading to providing taking Decison ALL 2 3 6 make sure all data correct Quickly handle errors Cost Department
falsified information
Divulge of confidential information to separation on

C3 unauthorized employees Fraud and risk in organisation ALL 1 4 4 responsibility in all all
department
C4 Inappropriate data backup procedures all procedure in organisation ALL 2 3 6 backup data monthely IT/ALL
C5 Wrong calculation and falsified reports Reports not accurate / data ALL 1 4 4 review data continuosly Quickly handle errors Cost Department
not reliable.
Hotel Services & Laundry
Ref Risk Impact Affected Likelihood of Magnitude of Rank Proactive Mitigation Active Mitigation Responsibility due date review date status remarks Likelihood of Magnitude of Rank
Department Occurrence Impact Occurrence Impact
Unavailability stop of work ,

HSL1 of special No available All Hospital 3 2 6
materials for clean supply for
the laundry. all hospital
Losing patients
clothes or
replacing them Patient
HSL2 during the complaint and Patient &Nursing 2 3 6
Departments
delivery bad reputation
(returning)
process.
Electricity and
water outages stop of work ,
HSL3 for a long No available All Nursing units 3 3 9
period in the clean supply for
laundry. all hospital
Wrong Patient
HSL4 charging of the complaint patient 2 1 2
laundry fees.
Infection and Patient

HSL5 complaint and laundry 2 3 6
work injuries.
bad reputation
Using
unsterilized/dir
HSL6 ty sheets and Rransmission of All Nursing units 1 4 4
textiles in the infection/Bad
patient’s Reputation
rooms.
unsatisfactory transmission of •developing guidelines for

level of infection/Bad effective cleaning •updating staffing Hotel Services
HSL7 cleanliness Reputation/pati All Hospital 3 5 15 •educating housekeeping plan •on job Apr.2017 Apr.2018 2 3 6
manager
allover the ent staff on the developed training
hospital dissatisfaction guidelines
not done due
to financial
delay in the laundry renovation and availability of three Hotel Services & proplems new due date:
HSL8 old machines cleaning process All Hospital 3 4 12 purchasing double acting bars linen Laundry, maintenance 9/017 9/018 (fluctuation of Dec.017
machines department
egyptian
pound)
staff education MSDS

refer to MSDS to
avilablity& updaed know the hazard of
PPE avialble the material.
spill kit approroprite to Seek medical
HSL9 Exposure to may affect the all hospital 4 4 16
deal with spill advice. Safety and hotel Apr.017 Apr.017 2 4 8
chemical hazrd health according emergency code ornage in Call the house services
to the type case of major spill keeping or activate
safety emrgency code orange in case
shower availble in laundrt, of major chemical
kitchen, lab, radiotherapy& spills.
chemotherapy
staff education identify

times of waste collection,
color coding of waste bags
including cytotoxic (purple)
and chemical and
pfarmaceutical waste
(orange) MSDS
Exposure to may affect the avilablity& updaed affected person to hotel services,
HSL10 hazardous health according hotel services 4 5 20 PPE avialble follow MSDS SAFETY, INFECTION Apr.018 Apr.018 2 4 8
waste to the type and laundry spill kit approroprite to instructions, CONTROL AND
deal with spill transfer to ER MEDICAL COUNCIKL
emergency code ornage in
case of major spill
safety emrgency
shower availble in laundrt,
kitchen, lab, radiotherapy&
chemotherapy
Information Technology
Ref Risk Impact Affected Likelihood of Magnitude of Rank Proactive Active Mitigation Responsibility due date review status remarks Likelihood of Magnitude of Rank
Unauthorized Review the access

users can access
Inappropriate to confidential Regular review right comperhensively
access (regarding data and the access rights and restrict access to IT / Security
IT 1 All 3 3 9 for all users as a the out of scope
segregation of information and scheduled information / data officer
duties). this lead to activity sources
information
leakage
reaching
unauthorized or Regular review Review the access
User obtains access confidential the access rights right comperhensively
IT 2 data /
permission over information All 3 4 12 for all users as a and restrict access to IT / Security officer
and the out of scope
than needed. this lead to scheduled information / data
information activity sources
leakage
Users might get reaching Review the access

unauthorized or
access to confidential Activate the rights
confidential data / proper comperhensively and
IT 3 information due to All 2 4 8 monitoring tools restrict access to the IT / Security officer
absence of access information and for the access of out of scope
monitoring this lead to users information / data
information
procedures. leakage sources.
Using
proffessional
criteria for the
Inappropriate process of
Wrong/inconsistent information
data due to Activity failure release and
multiple systems process deployment Restrict the access to
IT 4 All 3 3 9 management the leaked IT / Security officer
running in parallel Interruptions and the process information
with overlapping Customer/patient of Change
scope dissatisfaction Management to
control of apps
integrations and
systems overlaps
Unauthorized
users can access Review the access
Regular review right comperhensively
Inappropriate to confidential the access rights and restrict access to
IT 5 access (regarding data and All 3 3 9 for all users as a the out of scope IT / Security officer
segregation of information and
duties). this lead to scheduled information / data
information activity sources
leakage
reaching
unauthorized or Regular review Review the access
User obtains access confidential the access rights right comperhensively
IT 6 permission over data / All 3 4 12 for all users as a and restrict access to IT / Security officer
than needed. information and scheduled the out of scope
this lead to activity information / data
information sources
leakage
Users might get reaching Review the access

access to unauthorized or Activate the rights
confidential confidential proper comperhensively and
IT 7 information due to data / All 2 4 8 monitoring tools restrict access to the IT / Security officer
absence of access information and for the access of out of scope
monitoring this lead to users information / data
procedures. information sources.
leakage
Using
proffessional
criteria for the
Inappropriate process of
Wrong/inconsistent information release and
data due to Activity failure
multiple systems process deployment Restrict the access to
IT 8 All 3 3 9 management the leaked IT / Security officer
running in parallel Interruptions and the process information
with overlapping Customer/patient of Change
scope dissatisfaction Management to
control of apps
integrations and
systems overlaps
Put invoicing
process and the
involved
program under
inaccurate control to Restrict any
financial balances prevent any modification on the
Changing invoices / transactions / invoice
IT 9 data after they are financial All 3 3 9 modification financial data on Application team /
final. statements system after the
after issuance realease Security officer
of the final
Customer/patient except with a invoice
dissatisfaction decision of a
committee
including the
concerned
parties
Stopping in
financial business
activities
Incomplete Comperhensivel
financial y verify the
Posting or monthly whole workflow
IT 10 end closing may not statements All 1 3 3 on system in Preform the month Application Team
occur. Unreached regular basis to end closing manualy.
Labors salaries
Services affected ensure its
due to unpaid availability
payable vendors
invoices/bills
Radiology reports unauthorized

change and Regular check on Prevent any access
IT 11 are edited after the uncertain results All 3 3 9 the protection of ability on the data of Application Team/
order is ended on Uncontrolled recorded data the reports after their Security officer
the system. final release
report
Lab reports are unauthorized

change and Regular check on Prevent any access
IT 12 edited after the uncertain results All 3 3 9 the protection of ability on the data of Application team /
order is ended on Uncontrolled recorded data the reports after their Security officer
the system. final release
report
potential
malicious
activities on Regular
network and data scheduled Comperhensively
Unauthorized sources review of review Network Network team /
IT 13 access to network. potential hacking All 2 4 8 Network security security and firewall Security officer
on information and firewall rules
sources
potential rules
information loss
or leakage
Missuse of Analyze the raised

technology and
Security breaches resources Holding a breaches cases and
due to low user Data or give the proper
regular security awarenss
IT 14 All 2 4 8 accordingly IT / Security officer
awareness of information awareness for all to all users as a
security issues. leakage users corrective action for
Data loss or
corruption such breaches
Implement
release and
deployment
process for any Implement release
Data loss due to case of release / and deployment for Application team /
uncontrolled Business process update.
IT 15 changes / release activities dropped All 3 3 9 Implement the mentioned case System team /
updates. change to controlit in a Security officer
systematic approach
management
process for
anyrequest for
change.
Activate alert in
Slowness/ the level of Re-assign the server
Application intrruptions in application resources to the
IT 16 performs business activities All 2 3 6 administration active application IT / Security officer
unexpectedly potential loss of to report any sessions
data / files apps violation
Slowness/
intrruptions in Replace storage
Prepare immediately and
IT 17 Storage failure. business activities All 2 3 6 redundant HDDs restore data from IT / Security officer
potential loss of backup
data / files
Slowness/ Follow the

intrruptions in
System interruption business complied Roll-back the
activities IT teams / Security
IT 18 due to uncontrolled potential loss or All 3 2 6 process of executed officer
data change. corruption of change unauthorized change
management
data / files
Disable network Regular

operation or slow Shared folders comperhensive
rate of resolving inaccessible review of all
network Network based network devices Transfer network Network team /
IT 19 interruption due to apps will stop All 3 3 9 configuration traffic to a valid range Security officer
obsolete & Potential and keep them of Ips
unmanaged local interruptions in
user activities up to data in
data network. CMDB
Single point of Redundant FW Fix the error

IT 20 failure for firewall All 2 3 6 IT / Security officer
hardware. installation immediately
Single point of redundant Mail Fix the error

IT 21 failure for mail All 1 2 2 server immediately IT / Security officer
server. installation
Servers /
Server room Network devices Regular
temperature is stop working monitoring of Call the engineering
IT 22 Business / service All 3 3 9 Server room / department to fix the IT / Security officer
higher than interruptions due Datacenter problem.
accepted. to devicess tempreature
stopping
Power interruption Slowness/ UPS connection Call the engineering

IT 23 for network intrruptions in All 3 3 9 to critical department to fix the IT / Security officer
equipment. business activities network devices. problem.
Slowness/
intrruptions in Infrastructure
business activities UPS connection Call the engineering
IT 24 Power interruption potential damge All 3 3 9 to critical department to fix the team / Service
for computers. of computers devices. problem. Desk team /
potential loss of Security officer
data / files
Slowness/ Enterprise
intrruptions in Antivirous Quarantine the
Denial of service business activities management on infected device(s) and
IT 25 due to worms & potential damge All 2 3 6 all DAFH PCs get rid of the IT / Security officer
infection, and
malicious attack. of computers with continious perform a full scan on
potential loss of definition
data / files update. all DAFH devices.
IP management,
Interruption of Slowness/ continious Transfer Internet to
IT 26 internet intrruptions in All 2 2 4 helathcheck on redundant line, call IT / Security officer
connectivity. business activities Internet the ISP.
connectivity.
Regular
Facing unexpected comperhensive
network review of all
performance Slowness/ Transfer network
IT 27 behavior due to intrruptions in All 3 3 9 network devices traffic to a valid range IT / Security officer
obsolete network business activities configuration of Ips
and keep them
equipment and up to data in
connections.
CMDB
Incapability to
perform business
tasks Annual plan for Increase knowledge in
IT 28 Absence of skills. Missuse of All 3 3 9 training and the specific subject. IT Management
awareness
technology and
resources
Network being Slowness/
down or intrruptions in Network
IT 29 uncontrollable due business activities All 3 3 9 typology review Fix the error Network team /
to improper hosting due to instability regularly. immediately Security officer
location (e.g. A/C). of network
Insecured IT
environment
Unsafe data and
information
Inability to discover Potential data Comperhensively
hacking activities and information Vulnerability review
IT 30 because of absence leakage / loss All 2 5 10 assessment and Network/system IT / Security officer
penetration test
of security potential regularly. security and firewall
management tools. malicious rules.
activities on
network and data
sources
Data backup
Slowness/ strategy set and
intrruptions in apply. Replace HW.
Loss of data due to business activities System team /
IT 31 server damage Potential financial All 3 3 9 Restore data from Security officer
loss due to data Redundant Backup
storage
loss readiness.
Long duration to Business / service Enhance the

readiness of HA Apply the business
IT 32 restore service back interruption All 2 5 10 and DR contingency plan. IT / Security officer
after a disaster. solutions.
uncontrolled
Inability to identify transactions Enforce users to use
actual users unauthorized Apply security
IT 33 because of All 3 4 12 policies without separate and different IT / Security officer
ID/Password transactions exceptions. accounts.
sharing disclosure. unidentified Apply users NDA.
changes
Easy cracking
passwords unauthorized Apply security Review the creacked
IT 34 (weak/no access All 2 4 8 policies without passwords and re-set
serious security them following the IT / Security officer
password, not breach exceptions. password policies.
logging off)
Secure all HW
Financial loss physically inside Replace the lost HW
Potential Infrastructure
IT 35 Loss or Theft of unavailability of All 2 3 6 IT locations and and restore data from team / Security
hardware service hosted on control the backup. officer
physical access
hardware and site visits.
Lack of capability to
recover the failed Provide
No backup for firewall redundant Switch up the main IT / Security officer
IT 36 Insecured IT
firewall hardware. environment due to All 2 5 10 firewall server FW server
open ports and (Palo alto)
absence of FW rules
Provide
IT 37 No backup for mail Email service failure
All 3 3 9 redundant mail Switch up the main IT / Security officer
server hardware. business failure
server mail server
Accept the risk if no

alternate line.
Failure in the Provide active Connect the existing
No UPS for network hospital network
IT 38 equipment. once the electricity All 2 4 8 UPS for critical UPSs to the Network IT / Security officer
down network devices devices when the
electrical current is
interrupted.
No backup for No service recovery Establish a new

IT 39 internet with every failure All 3 4 12 contact with Accept the risk if no IT / Network team
from ISP alternate line
connectivity. additional ISP
Potential failure in Readiness of the
network due to updated as-built
damge or technical drawings for all using the existing
No as-built drawing problem in cabling network firmware of the
IT 40 for network cables. Potential business All 3 4 12 installations, to devices' vendors to IT / Network team
downtime to fix any be in place along trace the ports and
potential problem with network points of each cable
in network in longer diagrams and
time typology
Readiness of
Shared folders alternate
inaccessible Switch the network
IT 41 Failurenetwork
of local area potential All 2 4 8 switches for high traffic to the alternate IT / Security officer
availability
interruptions in switches
user activities redundant
connecations
Run the BCP test

Service failure / regularly to Establish BCP and DR
unavailability ensure the
IT 42 Failure of hospital Potential All 2 4 8 availability of server to recover IT / Security officer
server unavailability of service and services at earliest in
service case of server failure
recovery in case
of server failure
Laboratory
Ref Risk Impact Affected Likelihood of Magnitude Rank Proactive Active Mitigation Responsibility due date review status remarks Likelihood of Magnitude Rank
monthly revision of
all clinical kits stock and once send to outside lab,purchasing
L 1 shortage in store intrupt the work departments 3 4 12 reached 50% ask for contracted labs and main store
supply
Color coding of
delay in TAT for samples acc to investigate cause
L2 emergency Delay of clinical all clinical 3 3 9 urgency, introduction
of delay and do lab and quality
samples decision departments of new LIS with
corrective action
interface and
barcoding
Delay of TAT
and decrease all clinical Updating of regular lab and bomedical
L3 old machines accuracy of departments 2 3 6 machines each 5 maintenance of department
years old machines
results
monthly revision of
shortage in delay in some blood stock and once ask for donation blood bank and
surgeries and all clinical reached 50% ask for
L 4 blood and blood sometimes life departments 3 4 12 supply and increase from relatives and financial
components threatining outside contracted hospital department
BB
exposure to orientation about

L5 biological risk of blood lab 2 4 8 using PPE,regular follow needle stick lab and infection
hazards borne infection hand hygiene and injury policy control
vaccination
Orientation about
L 6 improper sample Delay of TAT all clinical 1 4 4 sample collection follow rejected lab
collection departments precautions to sample policy
phlebotomist
Following
wrong result preanalytic
preanalytic which lead to all clinical precautions
L 7 precautions not wrong clinical departments 2 4 8 regarding proper resampling lab
followed
decision sample and patient
identification
wrong result Asking for full

improper sample which lead to name and medical lab and medical
L8 identification wrong clinical DAF 2 4 8 number before OVR records
decision releasing of results
Providing UPS for

equipment to work in OVR and sending
L9 electricity shut Delay of TAT all clinical 3 3 9 case of electricity cut memo to depts that lab, engineering
down departments -off,OR provision of test results will be dept
electric generator delayed
especially for lab
chemists and
technicians must
the work give a mandatory at
timetables will least 1 month notice
providing proper before leaving (if
be disrupted incentives for
which will have lab and all severe defect will
chemists and
L 10 staff turnover an overall clinical dept 3 3 9 technicians to retain
occur notice period HR dept and lab
should be
negative effect them and prevent
lenghtened) during
lab operation high turnover which hiring and
and lab results training of new
personelle should be
done
before result
typing mistakes inaccurate lab released the result is OVR, investigate
L 11 all clinical 3 4 12 verified and the cause and do lab
in result result, wrong departments confirmed by lab proper corrective
documentation clinical decision doctor to check for action
typing mistakes
fix cause of power

equipment will provision of failure and make
L 12 power failure not fuction and all clinical 1 5 5 memeo dept. To
electric generator inform lab and
thus will cause departments them that engineering dept
delay in TAT for lab equipent results will be
delayed
regular
equipment will maintenance of
water supply not fuction and all clinical water station and investigate cause of lab and
L 13 shut down thus will cause departments 1 4 4 provision of delay and do proper
engineering dept
backup supply of corrective action
delay in TAT distilled water in
case of emergency
regular trying to find a

maintainence of backup fridge ASAP /
the cold chain of blood bank fridge, in case of failure to
the blood units have a do so send memo to
will not be contengency plan depts to inform
L 14 Failure of Blood maitained and all clinical 1 5 5 where there is a them about lab and biomedical
Bank Fridge therefore the departments backup blood
inavailability of safe depts
blood and
blood units may fridge to place the investigate cause of
not be fit for use blood in case of fridge failure and do
emgergency/ proper corrective
fridge failure action
Improper increase the fire fire resistant safety

L 15 storage of lab 3 5 15 cabinet to store engineering dep. Jul.017 Aug.017 done 3 2 6
chemicals hazard these chemicals
Material Management "Store"
Ref Risk Impact Affected Likelihood of Magnitude of Rank Proactive Active Responsibility due date review status remarks Likelihood of Magnitude of Rank
Department Occurrence Impact Mitigation Mitigation date Occurrence Impact
inventory of
supplies&materials
contain quantinty,
Transfers between Inaccurate expiry date& the supplies will
MM warehouses are not Data of reorder level be returned
1 properly prepared, current store Store 1 3 3 double cheching back to the Store
safeguarded, recorded done by the vendor
and accounted for. recevied staff
inspection
committee is done
Physical inventory inventory of

counts not being supplies&materials
performed based on contain quantinty,
appropriate procedures Loss of expiry date&
MM may result in a physical Store & Finance 2 4 8 reorder level Store
2 difference between the inventory receving
book and actual values, department will
and the misstatement sign on the
of inventory balances. received
The Hospital’s the security will

Security rounds deal&
MM inventories are not Loss of
ALL 1 4 4 and monitoring inspection to Security
3 properly safeguarded/ physical with cameras all suspected staff
destruction, loss or inventory the time camera will
theft of inventories. be reviewed
Incomplete inventory re counnting&

postings may result in Inaccurate biannual physical inspection to
MM the misstatement of Data of Store 2 3 6 count by the identify the Store
4 inventory in the current store financial deprtment source of
financial statements. defect
inventory of
supplies&materials
contain quantinty, the damged
Damaged, slow-moving expiry date& items will be
MM or obsolescent Delay in reorder level dicarded&
5 inventory is not providing Store 3 3 9 double cheching alternative store
properly identified and supplies done by the supplies will be
reserved for.
recevied staff used
inspection
committee is done
Material Management "Store"
contniouse
temprature
monitoringof
stoore room call maintence&
MM Inappropriate storage Corruption or Store & Finance 2 3 6 temperaure& biomed in case store
6 conditions may result in damage of refrgerator out of range
spoilage. stored items temperature teperature
storage
precaution
complaince
Users are granted Tracing the user

name of the
inappropriate access to worng
create/change/delete transaction,
inventory master data, Inaccurate IT Departmen limit solving the
MM resulting in Data of Store 3 4 12 the authority and transaction IT & Material
7 inappropriate or current store access to FMIS to then management
unauthorized master specified persons punishment of
data that may be the person who
invalid/unavailable for made the
purchase. mistake
Delay in
providing
service,
inappropriat
MM High turnover in e storage staff planning& one clerk from
Store 2 2 4 avilablity of cover other store will Store & HR
8 warehouse clerks. due to lack of
knowledge of to all store cover
hospital
policies and
procedures
Increasing the ordering

lead time and invalid
MM stock reorder limits that Delay in
9 does not match with providing ALL 3 4 12 Store
the hospital supplies
consumption.
Material Management "Purchasing"
Fire drills, Training
of staff on fire
MM probability of safety, Safety Code Red
10 Fire hazards. fire ALL 2 5 10 rounds to check on activated Safety
the fire extingishers
and hosereel and
fire alarm system.
Bad storage ,
shrinking the outside store
MM Storing places not quantity of stock level not
sufficient for keeping stored items, Store 3 3 9 Store
11 exceed the reorder
the hospital stock storage up to level
the ceiling in
some places
issuing a list of
MM Lack of supplies in the Shortage of critical supplies and using the Material
12 market. supplies ALL 3 4 12 providing a storage stored management and
enough for 6 quantities Finance
months
inspection is
Collusion between done by human
MM procurements Increase of code of ethics is resources& the Material
Finance 2 4 8 included in the
13 personnel and the prices calimed staff management
suppliers. supply chain will be
terminated
Helplessness in dealing
MM with supplier price Increase cost ALL 3 4 12 Material
14 increases. of goods management
Material Management "Purchasing"

suppliers
control the the committee
prices, of supply chain
MM OneSource suppliers. delivery of Requesting 2 4 8 tendre advertised has the right to Material
15 goods and departments at newspapers accept, cancel management
decrease or readverdise
availability of in news papers
all supplies
we contact the
vendor to solve
Poor supplier Low quality vendor evaluation the issues& if
MM performance or, worse, of supplies, Requesting 2 3 6 before starting not solved the Material
16 allocation or loss of shortage of departments management
supply. supplies annual evaluation cobtract will be
terminated if it
is not agent
expected prices
idenfied by the
Fragmentation and loss user with the contact with
MM of procurement Not Suitable Requesting 2 4 8 purchasing order to the finance to Requesting
17 negotiating leverage. price departments set the average of reset the Departments
price purchased expected price
items
Increase of issuing a list of

prices, delay critical supplies and using the
MM Fluctuations in the of providing all 5 4 20 providing a storage stored Finance Jan.017 Jan.017 done 4 3 12
18 exchange rates supplies and
inavailability enough for 6 quantities
of supplies months
Medical Records & Biostatistics
Affected Likelihood of Magnitude Proactive Active review Likelihood of Magnitude
Ref Risk Impact Department Occurrence of Impact Rank Mitigation Mitigation Responsibility due date date status remarks Occurrence of Impact Rank
Unauthorized Leads to provision Medical Correction of I.T, medical

amendments or of wrong data records Strict authorization error by records
information to
MR 1 misappropriation of health care admin - finance dept 4 3 12 supervision authorized admission , ER,
patients’ employee - Unit good training person out patient
information. secretaries
Loss of data (data Leads of delay to get Units To have full

awareness when Corrections of Medical records
MR 2 stored on the information - OPD 2 3 6 distributed file in errors staff
system) - ER the mobile shelves
The medical file may

remain for a long
time in other To make good
Leads delay of Units follow up for all file
department with no response when the - OPD have been Corrections of Medical records
MR 3 valid reason or file is required - ER 5 2 10 distributed outside errors staff
without tracing or
return the file back the medical records
dept
to the medical
records.
Maximize the
Delay in extracting utilizaton of the
the patient’s files Delay of response available space to
MR 4 and Failure of the when files are OPD 5 3 15 store all the Correction by maintenance Feb.017 Mar.017 done 2 3 6
mobile shelves requested - ER medical records maintenance Department
functioning. correctly and
fasten the scanning
system
The Automated
Automated chemical
Medical chemical system powder system
MR 5 The risk of fire or any It may lead to lost
catastrophe medical files records , ER , 1 5 5 should protect the will when
activated Security Dept
OPD and units medical records something
Dept from this risk happened
Nursing
Affected Likelihood of Magnitude of Active review Likelihood of Magnitude of

Ref Risk Impact Department Occurrence Impact Rank Proactive Mitigation Mitigation Responsibility due date date status remarks Occurrence Impact Rank
Low nurse to
Nursing
patient
department/Med
Staff High ratio/defective reallocation Director of
N1 ical & Surgical 4 3 12 Staff retension plan
turnover. nurses of nurses nursing/HR
units/All nursing
education/malpr
special units
actice
Modify the working

reallocation
Nursing schedule/facilitate
Low nurse to of
department/Med the trasport and
Staff patient nurses/discip Director of
N2 ical & Surgical 3 3 9 accomodation of
Absenteeism. ratio/delayed lianry actions nursing
units/All nursing nurse/coordinate
care provision in case of re-
special units accomodation for
occurrence
nurses children
Head hunting of
Low nurse to nurses/expand the
Nursing
patient scope of searching
department/Med
Inadequate ratio/delayed for nurses/try to reallocation Director of
N3 ical & Surgical 4 3 12
staffing levels care modify the labor of nurses nursing/HR
units/All nursing
provision/malpra roles for forign
special units
ctice nurses/extratime with
more money
consumables
unethically Nursing
charging orientation all materials charge
Charging of paying the department/Med
givin for all the avelabile on nurse/nurse
N 4 consumables not patient for a ical & Surgical 5 2 10
staff /special treining all the supervisor /
done service not units/All nursing
givin on the special hospital word clerk
provided special units
areas of the hospital
Unsafe practice
make sure
due to 24hr
Nursing on 24 hour shift the that a staff to
shifts causing Low quality of
department/Med staff nurse will recive replace her
exhaustion services nursing
N5 ical & Surgical 3 4 12 2 times break of 30 and a place
(nurses’ provided/patient supervisor
units/All nursing min and 2hour for for 2hour rest
productivity may harm
special units rest will be
differ during the
avelabile
shift)
Needlestick
all emplooyes of the
injuries/cut and
hospital are reciving identify ,
stab injuries from
a proper treainig of egnolege infection control
sharp objects, as Staff exposure
neddle use and west and departament/
N6 well as the to hazardoud Nursing 4 3 12
segregation upon implement nursing
additional risks organisms
hiring safty medical departament
of infection by
once per year the divaice
blood-borne
treaining is repeted
pathogens
Exposure to
dangerous
chemicals,
medications and
cleaning
material of safty
solutions that train all emplooyes of
MSDS departament/
can be absorbed safe work +
avelabile and quality
N 7 through the skin Staff harm Nursing 1 5 5 preventing masures
the SPIL KIT departament/
or inhaled. Long- knows were are
and the eye nursing
term exposure to the MSDS material
washer departament
these
substances in
hospitals
presents health
risks.
adhere strict
to all policies
and
miscommunicati
Lack of Nursing procedure
on between
documentation department/Med training/continous regarding nursing
healthcare
N 8 (incomplete or ical & Surgical 3 4 12 review and documentati supervisor /
staff/missed or
inaccurate units/All nursing coorection on ; were to education office
wrong provision
documentation) special units locate them/
of service
and fup by
the cilinical
instructir
Nursing
induction program policie and
department/Med
givin to all the staff protocol
N 9 Medication Error patient harm ical & Surgical 2 5 10
including the training medication ;
units/All nursing
of 6 safty goal verbal order
special units
policies and
procedure of
miscommunicati Nursing
induction program critical value quality
Poor on between staff department/Med
givin to all the staff reporting departament/
N 10 communication and between ical & Surgical 5 2 10
including the training /reciving/doc nursing
skills & attitude staff and units/All nursing
of 6 safty goal umentation supervisor
patients special units
avelabile on
the hospital
materials
avelabile on
the units
hand
Not following Nursing all staff
hygeine infection control
isolation department/Med knowledgeable about
spread of program + departament/
N 11 precautions/infec infection ical & Surgical 1 5 5 infection control
tion comtrol surveiliance nursing
units/All nursing policies and
policies program departament
special units procedure
informative
material
avelabile on
the hospital
patient
should be
examined by
nursing
putting a screening the physician
outpatients fall increasing departament
N 12 outpatients 4 4 16 process for all and if it is a May.017 JUL.017 done 2 4 8
with injury patient morbidity and medical
outpatients must some
council
radiological
examination
will be done
Outpatients
Ref Risk Impact Affected Likelihood of Magnitude Rank Proactive Active Responsibility due date review status remarks Likelihood of Magnitude Rank
Department Occurrence of Impact Mitigation Mitigation date Occurrence of Impact
Suggest an
Patients complaints, Call doctor alternative
Doctors Delay or no- Decrease of quality before time to doctor on the
show cases Affects the Service , patient OPD, Medical confirm arrival same day or OPD Supervisor
OP1 quality and forego cancellation, decrease Recrds, 4 3 12 time. In case of postpone Medical Council
revenues number of patients, Nursing delay send SMS appointment
lost revenues and to patients with same
waste time of patients
doctor
Decrease revenues, IT Dept is

stop lab& radiology preparing an
orders, can't reach the OPD, LAB, alternative
patient's data, RAD, IT, solution. IT Department
System breakdown Meanwhile
OP2 (Failure of IT System) increase patients Doctors, 2 5 10 OPD works Finance Department
complaints, doctor Medical manual after OPD
stay long time in Records approval of
rooms and Finance
Miscommunication Department
Decrease Number of
patients, increase Cancel
OPD, Puchasing appointment Purchasing
OP3 Out of Stock Medical patients complaints, Nursing, 1 4 4 Department Follow up with Department OPD
Supplies bad experiences for Doctors. complete stock purchasing Head Nurse
the patients & lost department
revenues.
stop Working, Bad Engineering

General engineering communication in Department, Close affected area
(A/C, Broken water OPD, increase Doctors, Preventative OPD makes a work
OP4 1 4 4 Maintenance
pipes, Telephone lines) patients complaints OPD& order
and lost Revenues Nursing
increasing the Call patients Availablity to

Patient’s no-show Call center & OPD
OP5 cases, number of un-show OPD 1 1 1 prior accept walk in supervisor
patients. appointment patients
arrange with
accounts
Charging the patient Assign a staff receivable to
OP6 with wrong category Patients complaints OPD 3 3 9 member for get approval OPD supervisor
daily revision from the
contracted
patients
Aggression of patients violent acts by train staff to
relatives that lead to solve problems Code Mr.
OP7 due to delayed damage of hospital OPD 3 3 9 and give Strong OPD Head
appointments. assets solutions
Losing patients Get a printed

medical files or Review files compy of the
dissemination of any affects the continuity daily and alarm medical records
OP8 of the medical file of patient care OPD 2 4 8 medical records electronic data department
information and to prepare and scaned
components. documents
Medication management
Ref Risk Impact Affected Department Likelihood of Magnitude Rank Proactive Mitigation Active Mitigation Responsibility due date review status remarks Likelihood of Magnitude of Rank
Occurrence of Impact date Occurrence Impact
Financial
1.Decreasing Pharmacy, Finance, department,
hospital profit Medical 3 2 6 Financial mitigation Financial mitigation medication
Increasing margin departments management
dep.
M 1 medication prices
due to exchange
rate fluctuations Financial
2.Increasing total Pharmacy, Finance, department,
value of purchased Medical 3 2 6 Financial mitigation Financial mitigation medication
medications departments management
dep.
Invoice of Pharmacy, Finance

Dispensing Reviewing the
received (Vendor accounts, Reviewing the invoice medication
M 2 medications could medications with Patients accounts, 4 1 4 addition by the
invoice addition by
management
incorrect price the responsible
be entered Accounts responsible pharmacist dep., Finance
and/or cost financial auditor
incorrectly receivable)
Possibility of Assigning
Dispensing expired
presence of Assigning pharmacists pharmacists to be
medications to the medication
M3 expired Pharmacy, Medical 12 to be responsible for responsible for
patients which can 3 4 management
medications on Departments medication expiry date medication expiry
cause harm to the dep.
the pharmacy checking every month date checking every
patient
shelves month
Employee
Precence of MSDS
exposure to Direct harm to
and training the Follow up the training medication
M4 hazardous employees leading 4
Pharmacy 1 4 pharmacist on how to of pharmacists in this management
medications due to their possible
deal with spills and regards dep.
to spills/damaged absence from work
broken vials
products
Following up, if the

Incorrect confusion is between
Similar drug
medication Apply the hospital specific medications, medication
M5 names may Pharmacy, Medical 6
dispensing may 2 3 policy regarding LASA large alert signs are management
cause wrong drug Departments
cause harm to medications made and training dep.
dispensing
patients the pharmacists in
this regards
Informing the
Biomedical
Failure of cooling Presence of UPS
department in this
medications due Medication damage Pharmacy, Finance, electric lines for Pharmacy,
M6 8 regards to seek any
to fridge (loss of hospital Medical 2 4 refrigerators, presence Biomedical
extra refrigerator in
malfunction/electri financial resources) departments of an extra refrigerator department
the hospital to be
cal shutoff (as a spare)
used to store
medications
Presence of security Presence of security
medication
cameras in the cameras in the
M7 Stealing Loss of hospital 4 management
Pharmacy, Finance 1 4 pharmacy, and pharmacy, and
medications financial resources dep., Security
conducting a weekly conducting a weekly
department
routine inventory routine inventory
1. Delay of Flexible pharmacy

Calling in a
Pharmacist pharmacy daily schedule able to medication
M8 Pharmacy, Medical 3 pharmacist from
absence in day tasks 2. 3 1 maintain operation in management
Departments home to cover-up the
shift Employee case of pharmacist dep.
absence
exhaustion absence
Pharmacists inform the

pharmacy
Calling in a
Pharmacist Night shift tasks management in case medication
M 9 absence in night 4 pharmacist from
delayed to the Pharmacy 2 2 they are unable to management
home to cover-up the
shift morning shift attend in a night shift dep.
absence
to manage the risk
earlier
Informing the affected Informing the

Unavailability of Shortage will affect medical department affected medical medication
M 10 medications in the some patients with Pharmacy, Medical
3 2 6 about the shortage department about the management
market (non the availability of Departments and the possible shortage and the dep., Medical
critical) some substitutes medication possible medication Council, DTC
substitutions substitutions
Radiology
Affected Likelihood of Magnitude of Proactive Active review Likelihood of Magnitude
Ref Risk Impact Department Occurrence Impact Rank Mitigation Mitigation Responsibility due date date status remarks Occurrence of Impact Rank
Errors of Reporting adherence to

False Positive high standards
Errors Injury to service of practice:
Incorrect Diagnosis user. Adverse Inpatients and Using
Qualifications, experienced
R1 3 2 6 Radiology
Poor Quality of publicity outpatients Experience, radiologists
Examination Reputation risk competency
Repeated Interruptions and Peer
review
Injury to service
Complications from user. Adverse Inpatients and adherence to Using
R2 intervention and publicity 2 3 6 high standards experienced Radiology
Medication Reputation risk outpatients of practice radiologists
Financial loss risk
Mis-Communication Compliance with Inpatients and Compliance Continuous

R3 between clinical and 3 3 9 Radiology
standards outpatients with standers training
radiology staff
Exposure to harmful Injury to service Inpatients and Compliance Regular Radiology-

R4 radiation user.Environmental outpatients 1 4 4 with standers maintenanc Biomedical
risk e
Injury to service Regular
R5 Misuse of equipment user. Inpatients and 2 4 8 Compliance maintenanc Radiology -
Environmental risk outpatients with standers e Biomedical
Injury to service Inpatients and Compliance Regular

R6 Corrupt data base users Financial loss outpatients 3 5 15 with standers maintenanc Radiology-IT Jan.017 Feb.017 done 2 5 10
risks e
Injury to service Regular
R7 Electricity failure users Financial loss Inpatients and
outpatients 3 4 12 Compliance Radiology-
with standers maintenanc Maintenance
risks e
Injury to service Inpatients and Compliance Regular
R8 HMIS/HIS/PACS failure users Financial loss outpatients 4 5 20 with standers maintenanc Radiology-IT Jan.017 Feb.017 done 2 5 10
risks e
Compliance with
R9 Patient fall standards Financial Inpatients and 3 4 12 Compliance Continuous Radiology
loss risks outpatients with standers training
Compliance with
R 10 Wrong patient standards Financial Inpatients and 2 4 8 Compliance Continuous Radiology
loss risks outpatients with standers training
Rheumatology and Rehabilitation
Ref Risk Impact Affected Likelihood of Magnitude Rank Proactive Active Responsibility due date review status remarks Likelihood of Magnitude Rank
Department Occurrence of Impact Mitigation Mitigation date Occurrence of Impact
Inpatients and
The possibility of work flow outpatients who Sufficient Overusing
RR 1 equipment failure. interruptio receive 2 3 6 equipment equipment Physiotherapist
n Physiotherapy
Failure to Inpatients and Increase Increase

provide the outpatients who Human
RR 2 staff shortage. departmen receive 3 4 12 number of workload on Resources
t services Physiotherapy working staff existing staff
Inpatients and Thorough Supervision

RR 3 Wrong diagnosis to wrong plan outpatients who
the patients. receive 1 5 5 history and and Physician
Physiotherapy examination reassessment
Performing
wrong
sessions to
the Inpatients and Proper
improper patients outpatients who documentatio
RR 4 documentation (other than receive 4 3 12 n and available Physiotherapist
prescribed Physiotherapy files
to him by
the
doctor).
Failure to Equipment has Equipement

RR 5 Loss of power provide the Whole 4 3 12 inherent only Porter
departmen department connected
t services inverter during use
Human Resources
Affected Likelihood of Magnitude of Proactive Likelihood of Magnitude of

Ref Risk Impact Department Occurrence Impact Rank Mitigation Active Mitigation Responsibility Due date review date status remarks Occurrence Impact Rank
*Probability of
Employees lack making mistakes
required skill set or *Decrease the
All the
HR 1 experience to quality of the hospital 2 4 8
perform job performance
responsibilities. Service
*we will lose

talented &
qualified
employees that
will be increase
Inability to retain employees
talented and qualified turnover
All the
HR 2 employees/ percentage hospital 3 3 9
employee *we will face
dissatisfaction. diffculty to recruit
talented candidate
in the medical
field
*increase the cost
of recruitment
*probability of
making mistakes
in working
operation
*Decrease the
Employees quality of the
development and performance
All the
HR 3 training plans are not Service hospital 2 4 8
developed and/or *probability of
executed. losing our
Customers
*We will lose
compettive role in
market
*Affecting hospital
reputation
*The hospital will
be unattractive for
Candidates
Labor law suits raised *feeling unsafe for
by terminated current employees
HR 4 employees result in that increase All the 2 4 8
hospital
affecting hospital turnover
reputation. *The hospital will
face legal
problems with
labour office
*Increase the time

Changing the work
HR 5 laws regarding hiring & cost of forigners Nursing Dept. 2 4 8
recruitment
foreigners procedures
Employee salaries
and other data may
be calculated and *employees
HR 6 employees 1 3 3
applied incorrectly dissatisfaction
during the payroll
calculations.
Invalid changes to
payroll master file
may cause
misstatement in *increase salaries
HR 7 financial statement cost HR 1 3 3
and / or unjustifiable
payments to
personnel.
Un-recorded
penalties resulting *repeated
HR 8 from violations of mistakes from employees 1 4 4
Dept.
labor law or related employees
regulations.
Establish informal
Inability to monitor
the conflict of groups and that
may pose a risk to All the
HR 9 interest issues inside the hospital hospital 2 4 8
the Hospital, due to
hiring many relatives. (e.g.,Workers
strike )
*Decrease the
quality of the
performance
Service *Create positive
*we will face *make exit working
diffculty to recruit interview for atmosphere by
talented candidate the resigned increased
High turnover In in the medical employees benefits for the
nursing, physicians All the
HR 10 and housekeeping field hospital 4 4 16 employees HR, department Jan.017 April.017 done 5 2 10
staff. *increase the cost *trying to solve managers
of recruitment the problems
*we will face a leading to
problem in the turnover
work operation &
it will increased
workload on
current staff
hiring an HR
director to
staff not applying apply new
current scientific uptodate
increase in staff All the done in
HR 11 knowledge in HR disatisfaction hospital 5 4 20 system with CEO Mar.017 Apr.017 ongoing Aug.2017 3 4 12
operations and not human capital
uptodate concept and
train HR staff on
it
Safety Department
Ref Risk Impact Affected Likelihood of Magnitude of Rank Proactive Mitigation Active Mitigation Responsibility Due date review status remarks Likelihood of Magnitude of Rank
Safety tour to the hospital

SD1 Exposed wires Electrical hazard All Hospital 3 3 9 every quarter education to contact the maintenance& safety Engineering& Safety
staff to not use expose wire deprtment
Safety tour daily Approprite

Unsecured PPE Electrical hazrd contact the maintenance& safety
SD2 Electrical hazard All Hospital 3 5 15 Engineering& Safety Feb.017 Feb.017 done 2 5 10
elctrical panel caution sign safety deprtment, incase of electrical hazard
tour every quarter transfer to ER
Safety tour daily Wear

SD3 High voltage Electrical hazard transformer 1 5 5 appropriate PPE Securing of the panels Engineering& Safety
electrical panel Electrical hazrd caution sign
Noise exposure laundry, loading Wear appropriate PPE if the place noise level exceed the
SD4 Noise more than 90db for dock, 2 3 6 Annual measure of the noise accepted decrease the time of Safety
8 hours affect the maintenace& level Audiometry exposure& wear appropriate PPE
health of staff machine room to staff of affected area
. Wear appropriate PPE

Follow safety precaution in
. Boilers work
heat exposure for . Laundry . Measuring temperature and
SD5 Heat strees long time affect the . Kitchen. 1 2 2 humidity periodically by decrease the time of exposure of staff Safety
health of staff CSSD. engineering department
annual measure of heat
stress
affect the quality of education to avoid direct contact the maintenace& safety
SD6 light work OR 3 2 6 contact with light deprtment Safety
regular tours
lead shield
radiation sign
Affect the health of radiation survilance medical investigation, advanced
the staff eg. Education& trainaing of medical investigation withdral
SD7 Radiation Chronic exposure radiology, cath 1 5 5 safety precaution all form work from one month two three Safety
exposure teratogic& lab, , OR, ER staff should wear the according to medical advice
leucopenia apprpriate PPE& TLD reeducation
periodic
investigation
daily survilance close the area contact the safety

Affect the health of monthly survilance officer/ physics wear the PPE
the staff eg. education of staff for safe Remove the waste& contaminated
SD8 Radioactive spill Chronic exposure Gamma 1 5 5 handling material surface to the radioactive waste room Safety
teratogic& camera& PET-CT safety data sheet to descripe till 10 half life of the material
leucopenia the hazard of radioactive contact then expert& radiation
material radio regulatory authuroity(refer to the
active spill kit radion safety program)
daily survilance
monthly survilance
Affect the health of education of staff for safe medical investigation, advanced
exposure to the staff eg. Radiotherapy handling material medical investigation withdral form
SD9 radiation Chronic exposure dep. 2 4 8 safety data sheet to descripe work from one month two three Safety
teratogic& the hazard of radioactive according to medical advice
leucopenia material radio reeducation
active spill kit radiation
safety program created
using caution wet floor sign

During cleaning during cleaning or any wet
Fall of staff, process, floor. -
SD10 vistors or harm or injury to construction, 3 4 12 using caution sign in case of medical care provided to the satff. Safety
employes the affected person renovation renovation. - avoid any Education staff
kitchen obstacles presence of stairs
lundary ramps.
laundry, nursing, Health education

physician, vaccination PPE education, refferal to ER , vaccination infection control&
SD11 exposure to infection housekeeping, 4 5 20 avialble spill kit if not vaccinated virology markers safety, medical reviewed Jan 017 done 3 3 9
Biohazrds porters and approroprite to deal with according to the level of exposure council monthly
technicians spill
staff education MSDS
avilablity& updaed
PPE avialble
spill kit approroprite to deal refer to MSDS to know the hazard of
Exposure to may affect the All staff dealing with spill emergency the material. Seek medical
SD12 health according to 4 4 16 code ornage in case of major advice. Call the house Safety Apr.017 Apr.017 done 2 4 8
chemical hazrd the type with chemicals spill safety keeping or activate code orange in
emrgency shower availble in case of major chemical spills.
laundrt, kitchen, lab,
radiotherapy&
chemotherapy
Emergency Room
hiring of the
High staff poor care creat a data base of previously
ER 1 turnover in delivered to the ER 4 3 12 interviewed ER physicians interviewed ER ER dep.
doctors and patients and nurses for possible physicians forom
nurses. hiring the database
ER 2 Malpractice (not bad reputation. ER 2 4 8 continious training RCA ER dep., DAFH

trained) of staff training center
Overcrowded
areas in ER, poor care accelerate both
ER 3 delivered to the ER 3 3 9 enforce triaging process admission and ER dep.
shortage in ER
receiving units. patients transfer processes
Bad attitude from

patients against staff communication skills Mr.Strong code ER dep., DAFH
ER 4 doctors and dissatisfaction ER 3 3 9 courses activation in case of training center
violence
nurses.
inability to deliver
care to the *regular maintenance, *all
patients using electrical devices are
ER 5 Electricity outage electrical ER 1 4 4 connected to the call the maintainence dep.
dependent generator, *some are maintainence dep.
devices and connected to the UPS
equipment
Disaster recovery
plan is not
properly failure of disaster *staff orientation, *drills, review action card ER & Quality
ER 6 all hospital 1 4 4 *action cards ( what to do
transmitted to management incase of disaster) for his role departments.
the different
parties
Improper
implementation failure of disaster *staff orientation, *drills, review action card ER & Quality
ER 7 for the disaster all hospital 1 5 5 *action cards ( what to do
management for his role departments.
plan incase of incase of disaster)
occurrence.
*affect patient create new code"STAT

crowdness of care in other trauma" to deal with policy approved and
ER 8 staff responsible units, * affect all hospital 4 4 16 minor casualities with staff activate STAT code ER & Quality Apr.017 Apr.017 developed but started in 2 4 8
for managing patient care in ER less than that in the departments. still not June 017
minor casualities due to crowdness Trauma code approved yet
Quality department
Affected Likelihood of Magnitude of Proactive Likelihood of Magnitude of
Ref Risk Impact Department Occurrence Impact Rank Mitigation Active Mitigation Responsibility due date review date status remarks Occurrence Impact Rank
restructioning of
lack of the the department motivation,
implementation of QPS hierarchy, valuble promotion & salary
program, coordination of related raise for old staff, CEO, Quality and
Q1 Quality staff turnover improvements, patient All Hospital 5 5 25 educational hiring of expeirienced HR departments Feb.018
safety and risk courses, staff with salary raise
management efforts developing career meeting the market
path level
Affect the Hospital development of

Reputation, loss of board reaccriditation
Q2 Loss of JCI accreditation confidence in the hospital All Hospital 1 5 5 plan approved Quality manager
leaders from the top
management
monitoring of patient
occurrence of sentinel event not reported safety goals and
to quality department, contributing Failure to identify and promote culture standards as hospital
factors:Lack of adequate quality manage risks to patient of safety, wide indicators, Quality and
Q3 improvement mechanisms for error safety, Inability to prevent All Hospital 4 5 20 developing an implementation is patient safety & Jun.018
reporting adverse events/outcomes electronic OVR reviewed quarterly Ethics committees
reporting system through the patient
tracers activities
inability to prevent risk management quality dep. &

Q4 Inadequate investigation of incidents incident recurrence All Hospital 3 5 15 course for hospital training center Mar.017 Mar.017 not done done in Apr.017 1 4 4
leaders
hospital wide
patient safety intensive analysis of Quality dep. And
Inadequate patient safety and soundness jeaperdouzing patient
Q5 All Hospital 3 5 15 KPIs, patient patient safety all hospital Dec.017
measures safety safety campaign related OVRs leaders
and tracers
quarterly quality
tracers and
Q6 Failure to conduct routine compliance jeaperdouzing patient All Hospital 3 5 15
development of Quality dep. Mar.017
audits safety & quality of care risk
management
program
Business Development
Likelihood of Magnitude of review Likelihood of Magnitude of
Ref Risk Impact Affected Department Occurrence Impact Rank Proactive Mitigation Active Mitigation Responsibility Due date date status remarks Occurrence Impact Rank
medical finance profession

review all patient bills before medical financial
professionals
issue .
Decrease in the receivables turn
BD 1 over, and increase in the decrease of cash finance , hospital 3 4 12
flow budget Apply clinical pathway to
receivable balances.
referenced to guideline to medical council
standerdize the care rendered
to the patien
Medical director is responsible for : -

Dealing with claims from insurance
medical finance profession company concerning medical errors or
Increase in the deductions review all patient bills before unclear indications of requested medical financial
BD 2 performed by the contracting dicrease of cash flow finance , hospital 4 4 16 issue . Apply clinical pathway procedures, treatment or professionals and Jan.017 Jan.017 done 2 4 8
budgget to reference guideline to the medical
companies stander dais the care given to investigations which may result in director
patient financial compensation by issuing a
case report containing needed
justifications.
Providing medical services agree with companies to have

without prior approval (the Loss of hospital finance , hospital clearance for 24 hours for finantial, billiing
BD 3 patients company might refuse 1 4 4 emergency cases, all elective and contracts
payments incase the hospital did resouces budget cases must have prior departments
not obtain prior approval) approval
Not achieving the sales and finance , hospital bussiness

BD 4 collection budget. decrease cash flow budget 2 4 8 increase the activity in the sales team development dep
Delayed Marketing campaigns decrease hospital more than one marketing plan bussiness
BD 6 does not achieve its goals rates finance (cash flow) 1 3 3 apply plan B development dep
Increasing the doubtful Accounts finantial, billiing

BD 7 balances dicrease cash flow finance 3 4 12 letter of credit convert to cash patient and contracts
departments
Increasing the competition level hospital , occupancy improve quality of service all hospital
BD 8 by other Hospitals rate will be decreased finance 4 4 16 rendered to the patients Rapid response to patient complaints leaders Nov.2018
BD 9 Depending on limited foreign hospital , occupancy finance , hospital 4 4 16 compansate the decrease internally top management strategic
market rate will be decreased budget plan 2018
For foreign patients, there is a risk finantial, billiing

BD 10 of not collecting the company Loss of hospital finance , hospital 2 4 8 dealing with black listed blacklist the not paying companies and contracts
fees resouces budget companies as cash patients departments
preset contract templates

prepared by the legal
representative of the hospital
Unfavorable Terms of Agreements Loss of hospital finance , hospital to be used by the hospital finantial, billiing
BD 11 2 3 6 and contracts
with contracting companies resouces budget during agreements , revision departments
of the issued contract by the
legal representative of the
hospital before finalization
ICU departments
Ref Risk Impact Affected Likelihood of Magnitude of Rank Proactive Active Mitigation Responsibility Due date review status remarks Likelihood of Magnitude of Rank
infection control
deterioration bunddles
ICU1 device related of the patient ICU 4 4 16 checklists, remove the device , ICU & infection Jul.017 Jul.017 done 2 4 8
infections condition regular blood antibiotic administration control
culture
sputum/urine
patient
experience
ICU2 violent acts by damage of ICU 3 3 9 courses activate code Mr.strong security dep
relatives hospital assets available for all
hospital staff
early family
violent acts by education on
relative refuse relatives that justification of activate code Mr.strong
ICU3 restraint for their lead to ICU 1 3 3 security dep
patients damage of the restraint and
hospital assets failed
alternatives
deterioration
of patient put the patient on
ICU4 vientilator failure condition ICU 2 5 10 Regular PM another ventilatoir, and ICU & biomedical
call biomedical engineering dep
engineering department
pressure ulcer
deterioration protocol,
ICU5 bed sores of patient ICU 3 4 12 training, follow treatment of nursing dep.
condition available air pressure ulcer and OVR
matresses
DVT
prophylactic
medications,
deep venous deterioration foot medical council,
ICU6 thrombosis of patient ICU 2 5 10 compression consultation & treatment nursing devices
condition devices, elastic
socks
*regular
inability to maintenance,
deliver care to
the patients *all electrical
ICU7 Electricity outage using electrical ICU 1 4 4 devices are call the maintainence maintainence dep.
connected to dep.
dependent the generator,
devices and available UPS
equipment
electrical oulets
enforce
premature compliance to
transfer of deterioration discharge
ICU8 of patient ICU 1 4 4 OVR, RCA medical council
patient out of the condition criteria of the
ICU patient from the
ICU
patients Adequate
ICU9 Wall suction requiring fluid ICU 2 2 4 Maintenance Use Portable Suction biomedical dep,
failure suction and PM ICU
Failure of
Central Lack of central
ICU10 Monitoring monitoring ICU, CCU 2 2 4 Regular PM call biomedical dep biomedical dep
System
call maintainence
dep.,Stop the admission
stopage of Periodic of patient in this rooms.
ICU11 postive& negtive poor isolation ICU 1 3 3 maintenace& Patients in negative maintainence dep,
rooms presure precautions monitoring of room pressure will wear ICU
pressure rooms
mask N95 till transferred
to another hospital
strategic risks
Contributing Factors liklihood of magnitude of
REF Risk Area Risk Description rank
Internal Factors External Factors occurrence impact
Mergers/Acquisitions/ Inadequate analysis of Absence of monitoring
ST1 Divestitures business partner on business partners 4 5 20
relationships
Business Concentration supplier overdependance Monopoly of certain
and Model equipment and drugs
ST2 5 5 25
by specific suppliers
Business Concentration Customer Absence of customers

ST3 3 5 15
and Model overdependence study and diversity
Business Concentration Dependency on facilities dependency on third
and Model not owned by the parties services
ST4 5 3 15
organization providers (Radioligy &
Lab. Services)
Customer/ Patients Inability to attract and Cutomer needs / comptetion
ST5 retain satisfaction / pricing 3 5 15
customers/Patients
Customer/ Patients Inadequate monitoring of Wekaness in public
customer/Patient's relations that leads to
ST6 4 4 16
preferences and needs failure in identifying
patients requirements
Customer/ Patients Insufficient patient Ineffective resources
volumes allocation and
ST7 4 4 16
utilization of DAF
assets and facilities
Operational Planning & Lack of growth in new or Absence of market and
Performance emerging markets feasibility studies to
ST8 4 5 20
Management expand locally and
regionaly
Operational Planning & failure to identify growth Lack of introducing /
Performance opportunities innovate medical
ST9 Management services which 4 4 16
represents growth
opportunties lost
Operational Planning & Inadequate consideration Flactutations of
Performance of external factors political and
ST10 Management economical 3 5 15
environment in the
local market
Operational Planning & Inadequate attention to Inadequate /
Performance business inaccurate feasibility
ST11 Management forecasts/expansion plans studies affecting 3 5 15
decision making
process
Outsourcing Loss of core competencies absence of timely competitors and
monitoring and market analysis
decision making
ST12 3 5 15
process to improve
underperformed
medical services
Outsourcing Absence of specific Absence of suppliers
supplier criteria qualification and
ST13 5 5 25
approved list of
suppliers
Pricing Inappropriate pricing of Absence of sufficient Faluctuations on the
products/services costing studies of medical sector
ST14 medical services and industry in Egypt 5 5 25
allignment of price list
with cost elements
Vision, mission & Values Failure to articulate a
ST15 vision statement that 3 3 9
inspires the orgainzation
Vision, mission & Values Failure to define the
ST16 mission of the 3 3 9
organization
Vision, mission & Values Failure to articulate
ST17 values for conducting 3 3 9
business
Physician Strategy and Poor relationship between Weakness in Market Culture
ST18 relationship DAF and physicians physicians contracting 5 5 25
process
Physician Strategy and no action taken regarding of Physicians continous
ST19 relationship poor physician outcome evaluations and 4 5 20
assessments
Physician Strategy and Inability to retain and
ST20 3 5 15
relationship attract Physicians
Operational Planning & Inadequate departmental Inaccurate allignment
Performance representation in plan of department business
ST21 4 5 20
Management development plans with DAF
strategic goals
Operational Planning & Unachievable plans Absence of monitoring
Performance tools and
Management accountability
ST22 5 5 25
standards in addition
to approved
departmental KPIs
Operational Planning & Inappropriate Weakness in allocating
Performance deployment of resources DAF resources
ST23 5 5 25
Management (equipment-facilities-
manpower)
Operational Planning & Inability to measure Absence of approved
ST24 Performance Performance departmental KPIs 4 5 20
Management
Operational Planning & Lack of Key Perfromance Absence of approved
ST25 Performance Indicators departmental KPIs 4 5 20
Management
Disaster Recovery & Inability to recover data Absence of approved
ST26 Business continuity BCP and its testing 5 5 25
planning
Disaster Recovery & Non-availability of critical Absence of approved
ST27 Business continuity resources when needed BCP and its testing 5 5 25
planning
Economic Conditions / Inflation / deflation Faluctuations on the
ST28 Industry Trends medical sector 5 4 20
industry in Egypt
Economic Conditions / Monetary and fiscal Faluctuations on the
ST29 Industry Trends policies medical sector 5 4 20
industry in Egypt
Economic Conditions / Political instability Faluctuations on the
ST30 Industry Trends medical sector 5 4 20
industry in Egypt
Economic Conditions / Corruption risk Absence of appropriate Market Culture
Industry Trends control environment
ST31 5 4 20
and control processses
Economic Conditions / Commodoties price risk Instability in the

ST32 Industry Trends drugs industry in the 5 5 25
Egyptian market
Economic Conditions / Inappropriate lobbying Governmental
ST33 4 4 16
Industry Trends lobyying
Economic Conditions / Foreign exchange rate
ST34 5 5 25
Industry Trends risks
External Fraud Vendor or business Absence of appropriate Market Culture
partner fraud control environment
ST35 5 4 20
External Fraud ineffective anti-fraud Absence of appropriate Market Culture

programs control environment
ST36 5 4 20
Hazards / Catastrophic Health epidemics Weakness in infection epidemics within the

ST37 2 5 10
loss control programs country
Hazards / Catastrophic Natural disasters Natural disasters
ST38 1 5 5
loss
Hazards / Catastrophic Man-made hazards / Absence of efficient Terror acts
ST39 loss terrorism security programs and 4 5 20
readiness
Philanthropy Lack of a well- Absence of a
ST40 documented documented and 4 2 8
philanthropic plan approved plan
Energy Management and Inadeqaute energy
ST41 3 5 15
alternative sourcing conservation
Waste Management Noncompliance with
applicable waste
ST42 3 5 15
management laws and
regulations
ST43 Waste Management High waste generation 3 5 15
Waste Management Inappropriate waste
ST44 treatment/reuse/disposal 3 5 15
practices
cardiac catheterization lab.
Affected Likelihood of Magnitude Proactive Active review Likelihood Magnitude
Ref Risk Impact Department Occurrence of Impact Rank Mitigation Mitigation Responsibility Due date date status remarks of of Impact Rank
Occurrence
education,
refferal to
Health ER ,
education vaccinatio
vaccination n if not
exposure to PPE vaccinated infection
CCL1 Biohazrds staff infection cathlab 2 5 10 avialble virology control& safety,
spill kit markers medical council
approroprite to according
deal with spill to the level
of
exposure
call
cath lab overload on regular biomedical biomedical
CCL2 machine out the other cathlab 1 3 3
of order machine maintainence dep for department
repair
unavailability difficulty in
of data of finding the a backup of the
implantable patient data is taken by
CCL3 having cathlab 1 3 3 IT dep.
medical recalled the IT dep
devices in implantable regularly
case of recall devices
Operation Room
Ref Risk Impact Affected Likelihood of Magnitude of Rank Proactive Mitigation Active Mitigation Responsibility Due date review status remarks Likelihood of Magnitude of Rank
Failure of Cannot perform
anesthesia procedures
machines
Regular PM, daily
OR1 OR 2 5 10 checking, checking call biomedical biomedical
before each surgery engineering engineering

laparoscopic laparscopy call biomedical OR & biomedical
OR2 System OR 2 3 6 Regular PM
engineering engineering

diathermy procedures
OR3 machines OR 3 4 12

operating tables procedures
OR4 OR 3 3 9
Negative affects control Periodic

OR5 pressure/Postiv of infection in OR 1 3 3 maintenace& Engineering
monitoring of Department
e pressure OR rooms pressure rooms
Health education education, refferal to

vaccination
exposure to PPE avialble ER , vaccination if not infection
OR6 Biohazrds staff infection OR 2 5 10 spill kit vaccinated virology control& safety,
markers according to medical council
approroprite to deal the level of exposure
with spill
Dialysis Unit
Ref Risk Impact Affected Likelihood of Magnitude Rank Proactive Active Mitigation Responsibility Due date review status remarks Likelihood of Magnitude Rank
risk of viral dialysis patients

infection deterioration are checked for
DU1 transmission to the of patient dialysis unit 1 4 4 viral infection RCA dialysis unit
before the first
patient by the condition session and
machine regularly
dialysis machine inability to regular call biomedical biomedical

DU2 continue dialysis unit 1 3 3 engineering
failure dialysis session maintenance engineering dep. dep.
patients develop following

complications guidelines for
during the dialysis deterioration monitoring of the
DU3 session e.g. of patient dialysis unit 2 2 4 patients during management of dialysis unit
complications
(hypotension, condition the session occuring during
hypertension, chest dialysis
pain,….)
dialysis patients
are considered
high risk for fall immediate
increasing assessment by
DU4 patient fall patient dialysis unit 1 5 5 and fall nurse then dialysis unit
morbidity precautions are physician , OVR,
implemented
without fall analysis tool
assessment
inability to
deliver care to *regular
the patients maintenance, *all
DU5 Electricity outage using electrical dialysis unit 1 4 4 machines has call the maintainence
dependent batteries and maintainence dep. dep.
devices and connected to the
generator
equipment
transmission of only trained staff follow infection
infection from deal with the control instructions
DU6 blood splashes infected dialysis unit 1 5 5 patient, wearing in case of blood dialysis unit
patient to staff of the PPEs splashes
deterioration monthly water cleaning & biomedical

DU7 contamination of of patient dialysis unit 1 5 5 checking by both disinfection of the engineering dep
water supply DAFH & ministry water tank and
condition of health repeat the sample & dialysis unit
Endoscopy Unit
Ref Risk Impact Affected Likelihood of Magnitude Rank Proactive Mitigation Active Mitigation Responsibility Due date review status remarks Likelihood of Magnitude Rank
perforation during deterioration

EN1 the endoscopic of the patient endoscopy 1 5 5 only priviliged consultants are medical council
procedure condition unit allowed to do the procedures
Remove to uncontaminated
EN2 Argon gas leakage suffocation endoscopy 1 5 5 proper storage (refer to MSDS) area, apply artificial safety
unit respiration if breathing department
stopped (refer to MSDS)
Remove to uncontaminated
leakage of effects similar endoscopy area, apply artificial biomedical
EN3 to general 1 4 4 suction connected to the device engineering
anesthestic gases unit respiration if breathing
anesthesia stopped (refer to MSDS) dep
staff education,MSDS refer to MSDS to know the

avilablity& updaed,PPE hazard of the material.
EN4 Exposure to sidex affect the endoscopy 1 4 4 avialble, spill kit approroprite Seek medical advice. Safety
staff health unit to deal with spill, emergency Call the house keeping or
code ornage in case of major activate code orange in case
spill of major chemical spills.
Failure of Cannot endoscopy call of biomedical

EN5 anesthesia perform unit 1 5 5 Regular PM engineering dep for repair BME
machines procedures
Cannot
EN6 Failure of perform endo endoscopy 3 3 9 regular Maintenance and PM call of biomedical BME
Endoscopies procedures unit engineering dep for repair
radiotherapy department
Likelihood
Ref Risk Impact Affected Likelihood of Magnitude Rank Proactive Mitigation Active Mitigation Responsibility Due date review status remarks of Magnitude Rank
Department Occurrence of Impact date Occurrenc of Impact
e
Affect the medical investigation,

health of the advanced medical
exposure to staff eg. Radiotherapy sheilded rooms, training investigation
RT1 Chronic 2 4 8 of staff, tld cards for staff withdral form work from Safety
radiation exposure dep. with regular checking one month two three
teratogic& according to medical
leucopenia advice reeducation
ONCOLOGY department
Ref Risk Impact Affected Likelihood of Magnitude Rank Proactive Mitigation Active Mitigation Responsibility Due date review status remarks Likelihood of Magnitude Rank
Exposure of staff to staff education, MSDS refer to MSDS to

ONC1 chemotherapy affect staff health oncology dep 4 4 16 avilablity& updaed, PPE know the hazard of Safety Apr.017 Apr.017 done 2 4 8
medications avialble,safety emrgency the material. Seek
shower availble medical advice.
identification confirmation
before ordering and
administration of
ONC2 patient identification wrong protocol oncology dep 1 5 5 chemotheraputics, double OVR pharmacist and
mix up ordering checking before prepatation oncology nurse
and delivery to the oncology
nurse
unfollowing the introduction of laminar air flow cabinate and

ONC3 infection control infections to oncology dep 2 5 10 follow infection control pharmacist
precautions for immunocompromized precautions
chemo preparation patients
deterioration in the double checking before disposal of the wrong pharmacist and
ONC4 wrong protocol order oncology dep 1 5 5 prepatation and delivery to the prepared
patient condition oncology nurse
oncology nurse chemotherapy
wrapping with aluminum foil

transfer of spoilage of prepared immediately after prep, disposal of the
ONC5 chemotheraputics chemotheraputics oncology dep 1 3 3 wrapping is checked by the prepared un wrapped pharmacist and
without alumenium oncology nurse upon receiving oncology nurse
wrapping (ineffective) from the chemo preparation chemotherapy
room
CSSD department
Affected Likelihood of Magnitude of Proactive Active review Likelihood of Magnitude
Ref Risk Impact Department Occurrence Impact Rank Mitigation Mitigation Responsibility Due date date status remarks Occurrence of Impact Rank
heavy duty
exposure of gloves, staff staff should
staff to burn affect staff training on seek medical CSSD and safety
CSSD1 health CSSD 2 4 8 advice in the dep.
hazards safe use of
equipment ER
remove the
indicators
high room spoilage of room away from CSSD and
CSSD2 temperature biological CSSD 3 4 12 temperature hot areas, call engineering dep
indicators monitoring engineering
department
Delay of TAT regular

and decrease all clinical Available maintenance bomedical
CSSD3 old machines accuracy of departments 2 3 6 backup of old department
results machines machines
orientation
exposure to risk of blood about using follow needle
biological borne PPE,regular stick injury CSSD and infection
CSSD4 CSSD 2 4 8 hand hygiene control
hazards infection policy
and
vaccination
equipment
will not regular call
water supply fuction and all clinical maintenance engineering
CSSD5 shut down thus will departments 1 4 4 of water engineering dept
department
cause delay station
in TAT
stop work
CSSD6 equipment Delay of TAT all clinical 3 3 9 and call biomedical
failure departments maintainence department
department
refer to the
infection
control risk Err:509
assessment
policy

Risk Assessment in Hospital

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Risk Assessment in Hospital

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Security

Any of the affect the Monitoring Cameras Security

loss any followup of the Engineering

Affected Likelihood of Magnitude review Likelihood of Magnitude

Delay in all process &

1. Can’t reach the

-Confirmation of data given by ID -Correction of faults

No-show cases from -Call the patient to know the

1.Missing -Use overhead

Unavailability * Partial/ * Provide stock * Find alternative /

BE 3 Electricity cut * Complete

Water supply Dialysis and Ensure Tanks Stop Unesseacary

Inadequate make an annual

Failure of non- Negative Adequate

Reagents and PM Plan Purchase new

Failure of foot Patients will ICU, CCU, Immediate

Failure of Cannot OR, Endo, ER, Immediate

Failure of Cannot Immediate

Failure of Cannot Immediate

The hospital had 2 water tanks

Pollution of poisoning of staff& The tanks were disconnected from

The other The other branch will automatically

new building, continouse The critical department as the OR,

The critical department as the OR,

Automatic The critical department as the OR,

Periodic Stop the admission of patient in this

Continouse education aboUt code presence of

Affected Likelihood of Magnitude of Likelihood of Magnitude of

Kitchen , Manual washing room

staff Injury, education to staff about

Kitchen , developing guidelines

Quickly handle errors &

Internal and external financial reporting Preparing financial reports

Roles and responsibilities in the financial

Reviewing data before

Reviewing data before

Errors in the reconciliation process Reviewing all the report

Financial assets and liabilities may be observation on daily basis

estabilish procedure and

In translation the subsidiaries financial

put policies and procedure

Bank accounts and responsibilities are

Bank accounts and responsibilities are

An employee may have the ability to

T3 No proper segregation of duties in cash fraud in treasury finance 1 3 3 separation on finance

Assets and liabilities denominated in not accurate financial

The Hospital may not account

Large cash amounts are not handled

Providing medical services to patients Patient accounts

Improper monitoring for the patients

PA 4 System breakdown or slow response Negative hospital image All 2 4 8

PA 5 High staff Turn Over Missing the experince Patient accounts 3 3 9

Budgeting and Financial analysis Process

Not all factors/elements taken into take into consideration all

Budget is not aligned with the Hospital's Supporting decisions with

staff retention plan, immediate interview with

Divulge of confidential information to separation on

Unavailability stop of work ,

Infection and Patient

unsatisfactory transmission of •developing guidelines for

staff education MSDS

staff education identify