[A proactive approach to risks: from responding tot leading]

To give an overview of instruments for early detection of quality and safety risks for integrated risk management in hospitals.Systematic literature review and qualitative research.A review of literature in three databases (PubMed, CINAHL and Embase) was conducted to establish which instruments are known from academic literature. Articles were selected if the effectiveness and feasibility of the instrument for risk management had been evaluated. We also examined the references of the articles found, and searched for grey literature. Moreover, 19 experts from healthcare and other sectors were interviewed in order to verify which instruments are used in practice and to study the factors influencing implementation in hospitals.We found more than 60 instruments which we divided into 12 categories. Interviewees reported that a combination of instruments is required in order to assess all of the quality and safety risks, the main elements being: (a) the patient as source; (b) brainstorming sessions and consultation in networks, i.e. verbal exchange of risks between departments and organisations; (c) insight into the performance of individual healthcare professionals and teams; and (d) site visits. For instruments to work as effectively as possible, a culture is essential in which care providers recognise and discuss risks. There is also a need for a management system including all hospital risks, allowing an integrated, efficient approach to risk.There are several instruments for early detection of quality and safety risks for integrated risk management in hospitals. The predictive value of the instruments requires further investigation.