Journal of Medical Safety 2009 (2) p.**- p.

** May, 2009

From Safety to the Risk Management Cycle

Dirk Proske
University of Natural Resources and Applied Life Sciences, Vienna, Institute of Mountain
Risk Engineering, Vienna, Austria

Abstract

The paper describes the development from the term “safety”, towards numerical expressions of it as
“risks” and finally the emerging concept of “quality-of-life”; in order to prove the fulfilment of the
requirement of “safety”. The paper starts with a definition of “safety”, but discusses also roughly the
term “optimal safety” and its limitations. The term “safety” is then transferred into the parameter of
“risk”. Since the earliest numerical expressions of “risk” the concept has experienced significant
development and many different risk metrics have been introduced subsequently. The evolution of
risk parameters and the consideration of optimal safety have finally yielded to the development and
application of “quality-of-life” parameters. It is worthwhile to note that this development has been
observed in many different scientific fields such as economy, engineering, social sciences and
medicine. However, the application of “quality-of-life metrics” yields to the same problem as using
the term “safety”. For a start it is extremely difficult to express “safety” in formal numerical
expressions. This is an unsatisfying situation since only formal decisions are testable. In contrast to
the common numerical time-invariant proofs of “safety” or the ultimate goal of “optimal safety”, the
new concept of “risk cycles” considers a never-ending development and change of conditions and
actions and impressively illustrates the limitation of common safety concepts. Therefore in the last
years the terms “risk management” and “risk cycle” have become widely applied.

1 Introduction using different metrics, such as probability

All human activities have to fulfil the requirement
of safety. Such requirements can be found in the
earliest law collections such as the one by
Hammurabi (Mann 1991). Therefore safety
concepts were introduced historically in many
technical fields; the first application of metrical
global safety factors can be traced back to Philo
von Byzantium around 300 B.C (Shigley &
Mischke 2001). Since this time many different
numerical safety concepts have been developed
measures or risk measures. An overview is given
in Proske (2008). However this development of
substitutes has yielded to a loss of the original
goal, the provision of “safety”.
2 Concept of safety
The term “safety” S is often defined as a situation
with a lower risk R compared to an acceptable
risk:

existing R ≤ permitted R → S
existing R > permitted R → S (1)
Journal of Medical Safety 2009 (2) p.**- p.**
or as a situation “without any danger impending”.
Other definitions describe safety as “peace of
mind” (Proske 2008). The former definition which
uses the term risk is already based on a
substitution; therefore the latter term using “peace
of mind” is a better definition. The author
considers “safety” to be the result of an evaluation
process of a certain situation done by every
system that is able to perform a decision making
process, such as animals, humans, societies or
computers. Whereas computers entirely use
formal numerical representation, humans and
societies may use informal measures and include
cognitive errors. Whether it is true or not that
humans and societies can visualise more than just
system borders in formal models is an important
issue but will not be discussed here (Proske 2008,
Gigerenzer 2004). However since all decisions
are finally done by humans, their “safety” is
understood as a feeling. Furthermore the
decision-making process deals with the question,
whether resources should be spent to decrease
hazards and danger to an acceptable level. In
S = { x | f ′′( x ) = 0}
Fig. 1. Assumed function shape between degree of relaxation and relative freedom of
resources
The degree of relaxation (DoR) can be evaluated
based on a function considering a number of
influence variables a, b, c,…:
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other terms “safety” is a feeling, which describes
that no further resources have to be spent to
decrease any threats. If one considers the term
“no further resources have to be spent” as a
degree of freedom of resources, one can define
“safety” as a region of a function which includes
the degree of freedom of resources. Furthermore
one can assume, that the degree of freedom is
related to some degree of distress and relaxation.
Whereas in safe conditions relaxation occurs, in
dangerous situations a high degree of distress is
clearly reached.
The possible shape of the function between
degree of relaxation which ranges from “danger”
to “peace of mind” and the value of the function as
degree of freedom of resources is shown in Fig. 1.
It is assumed here, that the relationship is non-
linear with at least one region of over-proportional
growth of the relative freedom of resources. In
Fig. 1 this region of maximum growth (point of
inflection) is defined as the starting point of the
safety region:
(2)
Journal of Medical Safety 2009 (2) p.**- p.**
DoR = f (a, b, c, d ...) (3)
These influence parameters need to be chosen.
As already mentioned, the term “safety” considers
subjective effects, such as trust, control or benefit.
Wojtecki & Peter (2000) have tried to introduce
some numerical equivalents for such conditions
and state that trust may shift the individual
acceptable risk by a factor of 2,000. That means,
if one convinces people through dialogue that a
house is safe, a much higher risk (no resources
are spent) will be accepted, whereas with only a
few negative words trust can be destroyed and
further resources for protection are spent. Many
additional factors, such as voluntariness, benefit,
control, age and experience can be considered
(see Proske 2008 or Covello et al. 2001). The
multi-variability indicates that the mathematical
formulation of such a degree of distress and
relaxation is complicated and often the most
important factors are identified by surveys.
At this point we should also look at “optimal
safety”. This term is widely used to assess the
efficiency of certain protection measures. Mostly
the Pareto criteria or the Kaldor-Hicks
Fig. 2. Function between degree of relaxation and relative freedom of resources
Fig. 2 indicates that humans do not reach a
maximum performance under extreme safe
conditions or high degrees of freedom of
resources. Instead, humans tend to return to
slightly unsafe regions leading to benefits not
illustrated in the figure. Therefore a time-invariant
optimal safety can not be computed. This fits very
well to the statement by Arrow et al. (1996), that
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compensation tests are used for the efficiency
assessment (Pliefke & Peil 2007). However such
measures are strongly based on formal numerical
expression and it is doubtful that such theories
can be directly related to the issue of safety.
Furthermore, in this instance “optimal safety” is
defined as a condition, which yields to a maximum
performance of humans, not a maximum utility.
Such maximum performance can be described in
relation to different degrees of stress and
relaxation by the Yerkes-Dodson-curve and is
shown in Fig. 2. It can be shown in the same
diagram format as Fig. 1 (Proske 2008). Finally
one may argue that maximum human
performance and maximum utility are the same.
Indeed, the major differences are the time
horizons which cause completely different results
(Münch 2005, Proske 2008). The question
remains, if “optimal safety” based on numerical
expressions is indeed related to “optimal safety”
assumed by individual humans and human
societies.
no risk based decisions are taken by humans;
only risk informed ones. However in engineering
sciences, subjective elements are usually
neglected and only formal numerical expressions
are used, mainly to fulfil liability requirements.
Here mainly risk parameters are used as
numerical expressions of safety. Some risk
parameters will be introduced in the next section.
Journal of Medical Safety 2009 (2) p.**- p.**
3. Risk Parameters
3.1 Mortalities
R = P ⋅C
Here, risk R is defined as a product of the
probability P of occurrence of an incident with
some negative consequences and the extent of
Fig. 3. Example mortalities for various situations/actions (Proske 2008)
As an example Fig. 3 lists some of the
frequencies of death for people in various actions.
In Proske (2008), a collection of over 125 values
for such mortalities in various situations or actions
can be found. Other adaptations of mortality
models using distances, areas, volumes, toxicity
measures and weights are also possible and in
use. When comparing such mortalities, one has to
consider the basic population and the date of data
gathering. However it seems to be that the highest
risks are risks of social failure, since in general the
infant mortality in Mali could be significantly
reduced and War should not be a common
occurrence in human societies.
Unfortunately the parameter does not give
evidence of how frequent a person was exposed
to a certain action over a time period. For example
people are exposed much longer to building
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The risk parameter of mortality corresponds with
the classical definition of risk, as it can be found in
many references:
(4)
the consequences C. Different units are possible
for the two components. This risk measure is
probably the oldest risk parameter (Proske 2008).
failure then to airplane failure over the course of a
year (Fig. 3). In order to improve the quality of the
risk measure, a calibration of time is necessary.
This risk measure is named “fatal accident rate”
which usually relates to the number of fatalities
over a standard time of 108 hours. Example values
can be found in Proske (2008).
3.2 Family of the F-N-diagrams
Mortalities and fatal accident rates do not consider
the extent of specific singular accidents. The
figures will be the same for an accident with one
fatality which occurs one thousand times, and an
accident with one thousand fatalities which occurs
only once. Experience has shown that people
differentiate strongly between these two cases in
regards to the subjective judgment. Such
subjective risk aversion can be shown in F-N-
Journal of Medical Safety 2009 (2) p.**- p.**
Diagrams. The first of these diagrams were
developed by Farmer (1967) for nuclear power
radiation. F-N-Diagrams became very famous in
the so-called Rasmussen-report in the beginning
of the 70`s of the last century (Proske 2008).
Since the introduction of the first diagrams, a huge
variety of such diagrams has been developed
using different units such as time, radiation,
energy and so on. A summary of various
representations of F-N-Diagrams can be found in
Jonkman et al. (2003); Ball & Floyd (2001); and
Proske (2008). The proof of “safety” can be done
graphically in such diagrams (Ball & Floyd 2001,
Proske 2008).
3.3 Lost life years
The family of the F-N-Diagrams is excellent for the
representation of technical and natural risks, as in
the cases of risks where high numbers of
casualties are possible. In cases of health risks,
the situation is more difficult. Additionally, the age
of the person concerned is not considered in F-N-
Diagrams or mortalities, but is usually considered
during subjective judgement. For example the
death of a person of 90 years of age, caused by
an illness, will be judged subjectively different,
than the death of a young person. The risk
parameter of the lost life years (LLE) considers
this effect. The parameter is defined as the
difference between average life expectation
without the analyzed action/situation and the
average life expectation including the
action/situation. This parameter is widely used in
the field of medicine, such as regarding cancer
treatment. Cohen (1991) collected lost life days
for various diseases and various social
circumstances. Further data can be found in
Proske (2008).
Fig 4. Representation of the concept of lost life years (Hofstetter & Hammitt 2003).
May, 2009
In addition to the loss of life years, it is possible to
consider health reductions during a life time and
to calculate the equivalent loss of life time. The
terms quality adjusted life years (QALY), disability
adjusted life years (DALY) or health years are
used equivalently. Fig. 4 clarifies these terms.
(Hofstetter & Hammitt 2003, Proske 2008). In
developed countries, the share of disability
adjusted life years amounts to about 10 % of a life
time, and in some of the African countries it is
almost 50 % (Proske 2008). Such numbers again
indicate a failure of social structures. This
situation is demonstrated in detail by Fig. 5, where
one can find poverty, poor social status or early
school drop out as the highest risk factors. Again
these are social failures. Therefore primarily we
can state, that the highest risks to humans are
social failures. Secondly we need some risk
parameters which are able to consider the status
of the social systems.
4. Quality-of-life Parameters
The building and development of social structures
is closely connected with the term quality-of-life.
Although the famous social critics of the 19th
century did not yet know the term quality-of-life,
they already regarded the improvement of the
circumstances of living as the main motivational
force of human development. One of the first
definitions of quality-of-life came from the field of
social charity science (Noll 1999). It was the
economist Pigou (1920) who coined the term
‘quality-of-life’ at the beginning of the 20th century
and who brought the term into academic
discussion as a target to reach for social actions
and as a measure of individual well-being.
Journal of Medical Safety 2009 (2) p.**- p.** May, 2009

Fig. 5. Lost life days in various situations according to Cohen (1991)

The development and usage of the term quality- to many other areas, e.g. medicine. In 1948, the
of-life, has since then, not only touched economy World Health Organization termed `Health` as a
and social science, but has also been introduced condition of absolute physical, mental, and social
Journal of Medical Safety 2009 (2) p.**- p.** May, 2009

well-being (WHO 1948). Over more than the last
fifty years, this definition has widened aims and
criteria for actions of physicians. Not only somatic
aspects of health and illness, but also
psychological and social aspects, the patient’s
well-being and their capacity to act are part of the
physician’s duty. This can all be summarised as
quality-of-life. “Health-related quality-of-life means
a psychological construct, which describes the
physical, psychological, mental, social and
functional aspects of the well-being and the
function capacity of the patients from their view”
(Bullinger 1996). Further definitions of quality-of-
life can be found in WHOQOL-Group (1994), Frei
(2003) or Proske (2008).
To comply with this definition new target metrics
(now known as health related quality-of-life
measure instruments) have been introduced. The
aim of this effort was to make quality-of-life
measurable and therefore making treatment
efficiency controllable. The application of quality-
of-life parameters is nowadays widespread in
preventive medical check-ups, in therapy
research, quality security and the health economy.
Thousands of scientific publications dealing with
this issue are now published every year (Bullinger
1996). These scientific strains led to the
development of over 1,500 quality-of-life
parameters in the field of medicine (Ahrens &
Leininger 2003, Frei 2003, Porzsolt & Rist 1997).
However the huge number of numerical measures
already indicates an emerging problem. According
to the respective definition, quality-of-life depends
on a number of variables, which are partly hard to
seize numerically. To visualise this, table 1 shows
input variable numbers, for the numerical
estimation of quality-of-life parameters for
psychiatric patients, which have been collected
tabular. The numbers of input variables for the
quality-of-life parameters differ tremendously.
Even the assembly of various quality-of-life
parameters for identical questions reveals
difficulties in the fixing of variables with a
functional connection.
In some publications, the possibility of a formal
metrical description of quality-of-life is
categorically excluded (Küchler & Schreiber
1989). Fig. 6 shows the high dimensionality of the
problem. However if one agrees with this
statement one loses the possibility to evaluate the
efficiency of mitigation measures in a formal
numerical way.

Table 1. Quality-of-life measure instruments for psychiatric patients (Frei 2003)

Quality-of-life measure instruments number of parameters
Social Interview Schedule (SIS) 48
Community Adjustment Form (CAF) 140
Satisfaction of Life Domain Scale (SLDS) 15
Oregon Quality-of-life Questionnaire (OQoLQ) 246
Quality-of-life Interview (QoLI) 143
California Well-Being Project Client Interview (CWBPCI) 304
Quality-of-life Questionnaire (QoLQ) 63
Quality-of-life Index for Mental Health (QLI-MH) 113
Quality-of-life in Depression Scale (QLDS) 35
Smith-Kline Beecham Quality-of-life Scale (SBQoL) 28
Quality-of-life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) 93
Journal of Medical Safety 2009 (2) p.**- p.**
Fig. 6. Dimension of quality-of-life according to Küchler & Schreiber (1989)
5. Risk Management Cycle
The evolution of the risk management process
started with the definition of safety, substituting
the term safety with the numerical representation
called risk. Observing that the highest risks are
social risks in different risk metrics; the term risk
has been transferred into quality-of-life measures.
Such quality-of-life measures may indeed be
applied to indicate optimal safety. A nice example,
either for the case of structural improvement of
bridges or for the application of adjuvant therapy
is shown in Proske (2008). However since the
numerical expression of quality-of-life is
represented by different metrics, which causes
problems, how useful are such investigations? On
the other hand resources are indeed limited and
have to be spent carefully. So what can be done?
Parallel to the development and application of
quality-of-life parameters, the focus on risk
management cycles has also increased in the last
decades. This can be seen, for example in a wide
range of codes and recommendations which deal
with this issue, not only in engineering, but also
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for the management of organisations (AS/NZS
2004, COSO 2004, IRGC 2005, Treasury Board
of Canada Secretariat 2001, UK Cabinet Office
2002) or natural hazards (Kienholz et al. 2004).
The difference between pure risk assessment
using either certain numerical risk parameters or
quality-of-life parameters is the consideration of a
permanent change of conditions and risks. There
will be no optimal solution, since the boundary
conditions also change and all mathematical
models proving an optimal solution simply fail by
realising that assumptions and conditions are
subject to change (SCM 2007). This constant
change is visualised in Fig. 7 as the Risk
Management Cycle. The possibility of failure is
already considered in its basis. As a conclusion all
of the mentioned numerical substitute measures
for safety, such as risk measures or quality-of-life
measures may be applied, although with caution
because their validity is limited to certain
conditions. However, such analysis can be
repeated regularly and irregularly.
Journal of Medical Safety 2009 (2) p.**- p.**
Fig. 9: Integral risk management concept as a cycle according to Kienholz et al. (2004)
6. Conclusion
Safety is a general requirement for all human
activities. Therefore it has to be decided in
advance whether a situation or action will be safe.
To prove the condition of safety formal numerical
measures have to be introduced. The most
common measures to describe safety numerically
are risk measures. However the evolution of risk
measures towards more realistic ones has shown
that quality-of-life measures may perform better
then pure risk measures, since they consider a
wider range of conditions. However quality-of-life
brings us back to the original problem, how can
such constructs be represented numerically? At
this point one should disregard the idea of a
finished safety assessment and consider it as a
permanently ongoing process. Although that is not
the original idea of risk management – it was
merely to widen the evaluative focus from one
scientific field to an interdisciplinary approach, risk
management yields to the risk management cycle
with never-ending development. If one returns to
the original term of safety which involves so many
subjective elements usually not considered by
numerical models, we clearly see that our
evaluation process may fail from time to time.
Such correctors are needed since our prognosis
capacity for biological or social systems is still
very limited as current economical developments
impressively show (Proske 2008).
May, 2009
7. AKNOWLEDGEMENT
The author wants to express his thanks to the
Austrian Research Foundation (FWF) for the
support of the study about indeterminacy and
safety concepts.
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Author: Dr. Dirk Proske
e-mail: dirk.proske@boku.ac.at
Postal Address: Peter-Jordan-Strasse 82, 1190
Vienna, Austria
Fax: 0043-1-47654/4390