Enterprise Risk Management Case Studies: Heroes and Zeros

By Andy Marker | April 7, 2021

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We’ve compiled more than 20 case studies of enterprise risk management programs that illustrate how companies can prevent significant losses yet take risks with more confidence.   

Included on this page, you’ll find case studies and examples by industry , case studies of major risk scenarios (and company responses), and examples of ERM successes and failures .

Enterprise Risk Management Examples and Case Studies

With enterprise risk management (ERM) , companies assess potential risks that could derail strategic objectives and implement measures to minimize or avoid those risks. You can analyze examples (or case studies) of enterprise risk management to better understand the concept and how to properly execute it.

The collection of examples and case studies on this page illustrates common risk management scenarios by industry, principle, and degree of success. For a basic overview of enterprise risk management, including major types of risks, how to develop policies, and how to identify key risk indicators (KRIs), read “ Enterprise Risk Management 101: Programs, Frameworks, and Advice from Experts .”

Enterprise Risk Management Framework Examples

An enterprise risk management framework is a system by which you assess and mitigate potential risks. The framework varies by industry, but most include roles and responsibilities, a methodology for risk identification, a risk appetite statement, risk prioritization, mitigation strategies, and monitoring and reporting.

To learn more about enterprise risk management and find examples of different frameworks, read our “ Ultimate Guide to Enterprise Risk Management .”

Enterprise Risk Management Examples and Case Studies by Industry

Though every firm faces unique risks, those in the same industry often share similar risks. By understanding industry-wide common risks, you can create and implement response plans that offer your firm a competitive advantage.

Enterprise Risk Management Example in Banking

Toronto-headquartered TD Bank organizes its risk management around two pillars: a risk management framework and risk appetite statement. The enterprise risk framework defines the risks the bank faces and lays out risk management practices to identify, assess, and control risk. The risk appetite statement outlines the bank’s willingness to take on risk to achieve its growth objectives. Both pillars are overseen by the risk committee of the company’s board of directors.  

Risk management frameworks were an important part of the International Organization for Standardization’s 31000 standard when it was first written in 2009 and have been updated since then. The standards provide universal guidelines for risk management programs.  

Risk management frameworks also resulted from the efforts of the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The group was formed to fight corporate fraud and included risk management as a dimension. 

Once TD completes the ERM framework, the bank moves onto the risk appetite statement. 

The bank, which built a large U.S. presence through major acquisitions, determined that it will only take on risks that meet the following three criteria:

  • The risk fits the company’s strategy, and TD can understand and manage those risks. 
  • The risk does not render the bank vulnerable to significant loss from a single risk.
  • The risk does not expose the company to potential harm to its brand and reputation. 

Some of the major risks the bank faces include strategic risk, credit risk, market risk, liquidity risk, operational risk, insurance risk, capital adequacy risk, regulator risk, and reputation risk. Managers detail these categories in a risk inventory. 

The risk framework and appetite statement, which are tracked on a dashboard against metrics such as capital adequacy and credit risk, are reviewed annually. 

TD uses a three lines of defense (3LOD) strategy, an approach widely favored by ERM experts, to guard against risk. The three lines are as follows:

  • A business unit and corporate policies that create controls, as well as manage and monitor risk
  • Standards and governance that provide oversight and review of risks and compliance with the risk appetite and framework 
  • Internal audits that provide independent checks and verification that risk-management procedures are effective

Enterprise Risk Management Example in Pharmaceuticals

Drug companies’ risks include threats around product quality and safety, regulatory action, and consumer trust. To avoid these risks, ERM experts emphasize the importance of making sure that strategic goals do not conflict. 

For Britain’s GlaxoSmithKline, such a conflict led to a breakdown in risk management, among other issues. In the early 2000s, the company was striving to increase sales and profitability while also ensuring safe and effective medicines. One risk the company faced was a failure to meet current good manufacturing practices (CGMP) at its plant in Cidra, Puerto Rico. 

CGMP includes implementing oversight and controls of manufacturing, as well as managing the risk and confirming the safety of raw materials and finished drug products. Noncompliance with CGMP can result in escalating consequences, ranging from warnings to recalls to criminal prosecution. 

GSK’s unit pleaded guilty and paid $750 million in 2010 to resolve U.S. charges related to drugs made at the Cidra plant, which the company later closed. A fired GSK quality manager alerted regulators and filed a whistleblower lawsuit in 2004. In announcing the consent decree, the U.S. Department of Justice said the plant had a history of bacterial contamination and multiple drugs created there in the early 2000s violated safety standards.

According to the whistleblower, GSK’s ERM process failed in several respects to act on signs of non-compliance with CGMP. The company received warning letters from the U.S. Food and Drug Administration in 2001 about the plant’s practices, but did not resolve the issues. 

Additionally, the company didn’t act on the quality manager’s compliance report, which advised GSK to close the plant for two weeks to fix the problems and notify the FDA. According to court filings, plant staff merely skimmed rejected products and sold them on the black market. They also scraped by hand the inside of an antibiotic tank to get more product and, in so doing, introduced bacteria into the product.

Enterprise Risk Management Example in Consumer Packaged Goods

Mars Inc., an international candy and food company, developed an ERM process. The company piloted and deployed the initiative through workshops with geographic, product, and functional teams from 2003 to 2012. 

Driven by a desire to frame risk as an opportunity and to work within the company’s decentralized structure, Mars created a process that asked participants to identify potential risks and vote on which had the highest probability. The teams listed risk mitigation steps, then ranked and color-coded them according to probability of success. 

Larry Warner, a Mars risk officer at the time, illustrated this process in a case study . An initiative to increase direct-to-consumer shipments by 12 percent was colored green, indicating a 75 percent or greater probability of achievement. The initiative to bring a new plant online by the end of Q3 was coded red, meaning less than a 50 percent probability of success. 

The company’s results were hurt by a surprise at an operating unit that resulted from a so-coded red risk identified in a unit workshop. Executives had agreed that some red risk profile was to be expected, but they decided that when a unit encountered a red issue, it must be communicated upward when first identified. This became a rule. 

This process led to the creation of an ERM dashboard that listed initiatives in priority order, with the profile of each risk faced in the quarter, the risk profile trend, and a comment column for a year-end view. 

According to Warner, the key factors of success for ERM at Mars are as follows:

  • The initiative focused on achieving operational and strategic objectives rather than compliance, which refers to adhering to established rules and regulations.
  • The program evolved, often based on requests from business units, and incorporated continuous improvement. 
  • The ERM team did not overpromise. It set realistic objectives.
  • The ERM team periodically surveyed business units, management teams, and board advisers.

Enterprise Risk Management Example in Retail

Walmart is the world’s biggest retailer. As such, the company understands that its risk makeup is complex, given the geographic spread of its operations and its large number of stores, vast supply chain, and high profile as an employer and buyer of goods. 

In the 1990s, the company sought a simplified strategy for assessing risk and created an enterprise risk management plan with five steps founded on these four questions:

  • What are the risks?
  • What are we going to do about them?
  • How will we know if we are raising or decreasing risk?
  • How will we show shareholder value?

The process follows these five steps:

  • Risk Identification: Senior Walmart leaders meet in workshops to identify risks, which are then plotted on a graph of probability vs. impact. Doing so helps to prioritize the biggest risks. The executives then look at seven risk categories (both internal and external): legal/regulatory, political, business environment, strategic, operational, financial, and integrity. Many ERM pros use risk registers to evaluate and determine the priority of risks. You can download templates that help correlate risk probability and potential impact in “ Free Risk Register Templates .”
  • Risk Mitigation: Teams that include operational staff in the relevant area meet. They use existing inventory procedures to address the risks and determine if the procedures are effective.
  • Action Planning: A project team identifies and implements next steps over the several months to follow.
  • Performance Metrics: The group develops metrics to measure the impact of the changes. They also look at trends of actual performance compared to goal over time.
  • Return on Investment and Shareholder Value: In this step, the group assesses the changes’ impact on sales and expenses to determine if the moves improved shareholder value and ROI.

To develop your own risk management planning, you can download a customizable template in “ Risk Management Plan Templates .”

Enterprise Risk Management Example in Agriculture

United Grain Growers (UGG), a Canadian grain distributor that now is part of Glencore Ltd., was hailed as an ERM innovator and became the subject of business school case studies for its enterprise risk management program. This initiative addressed the risks associated with weather for its business. Crop volume drove UGG’s revenue and profits. 

In the late 1990s, UGG identified its major unaddressed risks. Using almost a century of data, risk analysts found that extreme weather events occurred 10 times as frequently as previously believed. The company worked with its insurance broker and the Swiss Re Group on a solution that added grain-volume risk (resulting from weather fluctuations) to its other insured risks, such as property and liability, in an integrated program. 

The result was insurance that protected grain-handling earnings, which comprised half of UGG’s gross profits. The greater financial stability significantly enhanced the firm’s ability to achieve its strategic objectives. 

Since then, the number and types of instruments to manage weather-related risks has multiplied rapidly. For example, over-the-counter derivatives, such as futures and options, began trading in 1997. The Chicago Mercantile Exchange now offers weather futures contracts on 12 U.S. and international cities. 

Weather derivatives are linked to climate factors such as rainfall or temperature, and they hedge different kinds of risks than do insurance. These risks are much more common (e.g., a cooler-than-normal summer) than the earthquakes and floods that insurance typically covers. And the holders of derivatives do not have to incur any damage to collect on them.

These weather-linked instruments have found a wider audience than anticipated, including retailers that worry about freak storms decimating Christmas sales, amusement park operators fearing rainy summers will keep crowds away, and energy companies needing to hedge demand for heating and cooling.

This area of ERM continues to evolve because weather and crop insurance are not enough to address all the risks that agriculture faces. Arbol, Inc. estimates that more than $1 trillion of agricultural risk is uninsured. As such, it is launching a blockchain-based platform that offers contracts (customized by location and risk parameters) with payouts based on weather data. These contracts can cover risks associated with niche crops and small growing areas.

Enterprise Risk Management Example in Insurance

Switzerland’s Zurich Insurance Group understands that risk is inherent for insurers and seeks to practice disciplined risk-taking, within a predetermined risk tolerance. 

The global insurer’s enterprise risk management framework aims to protect capital, liquidity, earnings, and reputation. Governance serves as the basis for risk management, and the framework lays out responsibilities for taking, managing, monitoring, and reporting risks. 

The company uses a proprietary process called Total Risk Profiling (TRP) to monitor internal and external risks to its strategy and financial plan. TRP assesses risk on the basis of severity and probability, and helps define and implement mitigating moves. 

Zurich’s risk appetite sets parameters for its tolerance within the goal of maintaining enough capital to achieve an AA rating from rating agencies. For this, the company uses its own Zurich economic capital model, referred to as Z-ECM. The model quantifies risk tolerance with a metric that assesses risk profile vs. risk tolerance. 

To maintain the AA rating, the company aims to hold capital between 100 and 120 percent of capital at risk. Above 140 percent is considered overcapitalized (therefore at risk of throttling growth), and under 90 percent is below risk tolerance (meaning the risk is too high). On either side of 100 to 120 percent (90 to 100 percent and 120 to 140 percent), the insurer considers taking mitigating action. 

Zurich’s assessment of risk and the nature of those risks play a major role in determining how much capital regulators require the business to hold. A popular tool to assess risk is the risk matrix, and you can find a variety of templates in “ Free, Customizable Risk Matrix Templates .”

In 2020, Zurich found that its biggest exposures were market risk, such as falling asset valuations and interest-rate risk; insurance risk, such as big payouts for covered customer losses, which it hedges through diversification and reinsurance; credit risk in assets it holds and receivables; and operational risks, such as internal process failures and external fraud.

Enterprise Risk Management Example in Technology

Financial software maker Intuit has strengthened its enterprise risk management through evolution, according to a case study by former Chief Risk Officer Janet Nasburg. 

The program is founded on the following five core principles:

  • Use a common risk framework across the enterprise.
  • Assess risks on an ongoing basis.
  • Focus on the most important risks.
  • Clearly define accountability for risk management.
  • Commit to continuous improvement of performance measurement and monitoring. 

ERM programs grow according to a maturity model, and as capability rises, the shareholder value from risk management becomes more visible and important. 

The maturity phases include the following:

  • Ad hoc risk management addresses a specific problem when it arises.
  • Targeted or initial risk management approaches risks with multiple understandings of what constitutes risk and management occurs in silos. 
  • Integrated or repeatable risk management puts in place an organization-wide framework for risk assessment and response. 
  • Intelligent or managed risk management coordinates risk management across the business, using common tools. 
  • Risk leadership incorporates risk management into strategic decision-making. 

Intuit emphasizes using key risk indicators (KRIs) to understand risks, along with key performance indicators (KPIs) to gauge the effectiveness of risk management. 

Early in its ERM journey, Intuit measured performance on risk management process participation and risk assessment impact. For participation, the targeted rate was 80 percent of executive management and business-line leaders. This helped benchmark risk awareness and current risk management, at a time when ERM at the company was not mature.

Conduct an annual risk assessment at corporate and business-line levels to plot risks, so the most likely and most impactful risks are graphed in the upper-right quadrant. Doing so focuses attention on these risks and helps business leaders understand the risk’s impact on performance toward strategic objectives. 

In the company’s second phase of ERM, Intuit turned its attention to building risk management capacity and sought to ensure that risk management activities addressed the most important risks. The company evaluated performance using color-coded status symbols (red, yellow, green) to indicate risk trend and progress on risk mitigation measures.

In its third phase, Intuit moved to actively monitoring the most important risks and ensuring that leaders modified their strategies to manage risks and take advantage of opportunities. An executive dashboard uses KRIs, KPIs, an overall risk rating, and red-yellow-green coding. The board of directors regularly reviews this dashboard.

Over this evolution, the company has moved from narrow, tactical risk management to holistic, strategic, and long-term ERM.

Enterprise Risk Management Case Studies by Principle

ERM veterans agree that in addition to KPIs and KRIs, other principles are equally important to follow. Below, you’ll find examples of enterprise risk management programs by principles.

ERM Principle #1: Make Sure Your Program Aligns with Your Values

Raytheon Case Study U.S. defense contractor Raytheon states that its highest priority is delivering on its commitment to provide ethical business practices and abide by anti-corruption laws.

Raytheon backs up this statement through its ERM program. Among other measures, the company performs an annual risk assessment for each function, including the anti-corruption group under the Chief Ethics and Compliance Officer. In addition, Raytheon asks 70 of its sites to perform an anti-corruption self-assessment each year to identify gaps and risks. From there, a compliance team tracks improvement actions. 

Every quarter, the company surveys 600 staff members who may face higher anti-corruption risks, such as the potential for bribes. The survey asks them to report any potential issues in the past quarter.

Also on a quarterly basis, the finance and internal controls teams review higher-risk profile payments, such as donations and gratuities to confirm accuracy and compliance. Oversight and compliance teams add other checks, and they update a risk-based audit plan continuously.

ERM Principle #2: Embrace Diversity to Reduce Risk

State Street Global Advisors Case Study In 2016, the asset management firm State Street Global Advisors introduced measures to increase gender diversity in its leadership as a way of reducing portfolio risk, among other goals. 

The company relied on research that showed that companies with more women senior managers had a better return on equity, reduced volatility, and fewer governance problems such as corruption and fraud. 

Among the initiatives was a campaign to influence companies where State Street had invested, in order to increase female membership on their boards. State Street also developed an investment product that tracks the performance of companies with the highest level of senior female leadership relative to peers in their sector. 

In 2020, the company announced some of the results of its effort. Among the 1,384 companies targeted by the firm, 681 added at least one female director.

ERM Principle #3: Do Not Overlook Resource Risks

Infosys Case Study India-based technology consulting company Infosys, which employees more than 240,000 people, has long recognized the risk of water shortages to its operations. 

India’s rapidly growing population and development has increased the risk of water scarcity. A 2020 report by the World Wide Fund for Nature said 30 cities in India faced the risk of severe water scarcity over the next three decades. 

Infosys has dozens of facilities in India and considers water to be a significant short-term risk. At its campuses, the company uses the water for cooking, drinking, cleaning, restrooms, landscaping, and cooling. Water shortages could halt Infosys operations and prevent it from completing customer projects and reaching its performance objectives. 

In an enterprise risk assessment example, Infosys’ ERM team conducts corporate water-risk assessments while sustainability teams produce detailed water-risk assessments for individual locations, according to a report by the World Business Council for Sustainable Development .

The company uses the COSO ERM framework to respond to the risks and decide whether to accept, avoid, reduce, or share these risks. The company uses root-cause analysis (which focuses on identifying underlying causes rather than symptoms) and the site assessments to plan steps to reduce risks. 

Infosys has implemented various water conservation measures, such as water-efficient fixtures and water recycling, rainwater collection and use, recharging aquifers, underground reservoirs to hold five days of water supply at locations, and smart-meter usage monitoring. Infosys’ ERM team tracks metrics for per-capita water consumption, along with rainfall data, availability and cost of water by tanker trucks, and water usage from external suppliers. 

In the 2020 fiscal year, the company reported a nearly 64 percent drop in per-capita water consumption by its workforce from the 2008 fiscal year. 

The business advantages of this risk management include an ability to open locations where water shortages may preclude competitors, and being able to maintain operations during water scarcity, protecting profitability.

ERM Principle #4: Fight Silos for Stronger Enterprise Risk Management

U.S. Government Case Study The terrorist attacks of September 11, 2001, revealed that the U.S. government’s then-current approach to managing intelligence was not adequate to address the threats — and, by extension, so was the government’s risk management procedure. Since the Cold War, sensitive information had been managed on a “need to know” basis that resulted in data silos. 

In the case of 9/11, this meant that different parts of the government knew some relevant intelligence that could have helped prevent the attacks. But no one had the opportunity to put the information together and see the whole picture. A congressional commission determined there were 10 lost operational opportunities to derail the plot. Silos existed between law enforcement and intelligence, as well as between and within agencies. 

After the attacks, the government moved toward greater information sharing and collaboration. Based on a task force’s recommendations, data moved from a centralized network to a distributed model, and social networking tools now allow colleagues throughout the government to connect. Staff began working across agency lines more often.

Enterprise Risk Management Examples by Scenario

While some scenarios are too unlikely to receive high-priority status, low-probability risks are still worth running through the ERM process. Robust risk management creates a culture and response capacity that better positions a company to deal with a crisis.

In the following enterprise risk examples, you will find scenarios and details of how organizations manage the risks they face.

Scenario: ERM and the Global Pandemic While most businesses do not have the resources to do in-depth ERM planning for the rare occurrence of a global pandemic, companies with a risk-aware culture will be at an advantage if a pandemic does hit. 

These businesses already have processes in place to escalate trouble signs for immediate attention and an ERM team or leader monitoring the threat environment. A strong ERM function gives clear and effective guidance that helps the company respond.

A report by Vodafone found that companies identified as “future ready” fared better in the COVID-19 pandemic. The attributes of future-ready businesses have a lot in common with those of companies that excel at ERM. These include viewing change as an opportunity; having detailed business strategies that are documented, funded, and measured; working to understand the forces that shape their environments; having roadmaps in place for technological transformation; and being able to react more quickly than competitors. 

Only about 20 percent of companies in the Vodafone study met the definition of “future ready.” But 54 percent of these firms had a fully developed and tested business continuity plan, compared to 30 percent of all businesses. And 82 percent felt their continuity plans worked well during the COVID-19 crisis. Nearly 50 percent of all businesses reported decreased profits, while 30 percent of future-ready organizations saw profits rise. 

Scenario: ERM and the Economic Crisis  The 2008 economic crisis in the United States resulted from the domino effect of rising interest rates, a collapse in housing prices, and a dramatic increase in foreclosures among mortgage borrowers with poor creditworthiness. This led to bank failures, a credit crunch, and layoffs, and the U.S. government had to rescue banks and other financial institutions to stabilize the financial system.

Some commentators said these events revealed the shortcomings of ERM because it did not prevent the banks’ mistakes or collapse. But Sim Segal, an ERM consultant and director of Columbia University’s ERM master’s degree program, analyzed how banks performed on 10 key ERM criteria. 

Segal says a risk-management program that incorporates all 10 criteria has these characteristics: 

  • Risk management has an enterprise-wide scope.
  • The program includes all risk categories: financial, operational, and strategic. 
  • The focus is on the most important risks, not all possible risks. 
  • Risk management is integrated across risk types.
  • Aggregated metrics show risk exposure and appetite across the enterprise.
  • Risk management incorporates decision-making, not just reporting.
  • The effort balances risk and return management.
  • There is a process for disclosure of risk.
  • The program measures risk in terms of potential impact on company value.
  • The focus of risk management is on the primary stakeholder, such as shareholders, rather than regulators or rating agencies.

In his book Corporate Value of Enterprise Risk Management , Segal concluded that most banks did not actually use ERM practices, which contributed to the financial crisis. He scored banks as failing on nine of the 10 criteria, only giving them a passing grade for focusing on the most important risks. 

Scenario: ERM and Technology Risk  The story of retailer Target’s failed expansion to Canada, where it shut down 133 loss-making stores in 2015, has been well documented. But one dimension that analysts have sometimes overlooked was Target’s handling of technology risk. 

A case study by Canadian Business magazine traced some of the biggest issues to software and data-quality problems that dramatically undermined the Canadian launch. 

As with other forms of ERM, technology risk management requires companies to ask what could go wrong, what the consequences would be, how they might prevent the risks, and how they should deal with the consequences. 

But with its technology plan for Canada, Target did not heed risk warning signs. 

In the United States, Target had custom systems for ordering products from vendors, processing items at warehouses, and distributing merchandise to stores quickly. But that software would need customization to work with the Canadian dollar, metric system, and French-language characters. 

Target decided to go with new ERP software on an aggressive two-year timeline. As Target began ordering products for the Canadian stores in 2012, problems arose. Some items did not fit into shipping containers or on store shelves, and information needed for customs agents to clear imported items was not correct in Target's system. 

Target found that its supply chain software data was full of errors. Product dimensions were in inches, not centimeters; height and width measurements were mixed up. An internal investigation showed that only about 30 percent of the data was accurate. 

In an attempt to fix these errors, Target merchandisers spent a week double-checking with vendors up to 80 data points for each of the retailer’s 75,000 products. They discovered that the dummy data entered into the software during setup had not been altered. To make any corrections, employees had to send the new information to an office in India where staff would enter it into the system. 

As the launch approached, the technology errors left the company vulnerable to stockouts, few people understood how the system worked, and the point-of-sale checkout system did not function correctly. Soon after stores opened in 2013, consumers began complaining about empty shelves. Meanwhile, Target Canada distribution centers overflowed due to excess ordering based on poor data fed into forecasting software. 

The rushed launch compounded problems because it did not allow the company enough time to find solutions or alternative technology. While the retailer fixed some issues by the end of 2014, it was too late. Target Canada filed for bankruptcy protection in early 2015. 

Scenario: ERM and Cybersecurity System hacks and data theft are major worries for companies. But as a relatively new field, cyber-risk management faces unique hurdles.

For example, risk managers and information security officers have difficulty quantifying the likelihood and business impact of a cybersecurity attack. The rise of cloud-based software exposes companies to third-party risks that make these projections even more difficult to calculate. 

As the field evolves, risk managers say it’s important for IT security officers to look beyond technical issues, such as the need to patch a vulnerability, and instead look more broadly at business impacts to make a cost benefit analysis of risk mitigation. Frameworks such as the Risk Management Framework for Information Systems and Organizations by the National Institute of Standards and Technology can help.  

Health insurer Aetna considers cybersecurity threats as a part of operational risk within its ERM framework and calculates a daily risk score, adjusted with changes in the cyberthreat landscape. 

Aetna studies threats from external actors by working through information sharing and analysis centers for the financial services and health industries. Aetna staff reverse-engineers malware to determine controls. The company says this type of activity helps ensure the resiliency of its business processes and greatly improves its ability to help protect member information.

For internal threats, Aetna uses models that compare current user behavior to past behavior and identify anomalies. (The company says it was the first organization to do this at scale across the enterprise.) Aetna gives staff permissions to networks and data based on what they need to perform their job. This segmentation restricts access to raw data and strengthens governance. 

Another risk initiative scans outgoing employee emails for code patterns, such as credit card or Social Security numbers. The system flags the email, and a security officer assesses it before the email is released.

Examples of Poor Enterprise Risk Management

Case studies of failed enterprise risk management often highlight mistakes that managers could and should have spotted — and corrected — before a full-blown crisis erupted. The focus of these examples is often on determining why that did not happen. 

ERM Case Study: General Motors

In 2014, General Motors recalled the first of what would become 29 million cars due to faulty ignition switches and paid compensation for 124 related deaths. GM knew of the problem for at least 10 years but did not act, the automaker later acknowledged. The company entered a deferred prosecution agreement and paid a $900 million penalty. 

Pointing to the length of time the company failed to disclose the safety problem, ERM specialists say it shows the problem did not reside with a single department. “Rather, it reflects a failure to properly manage risk,” wrote Steve Minsky, a writer on ERM and CEO of an ERM software company, in Risk Management magazine. 

“ERM is designed to keep all parties across the organization, from the front lines to the board to regulators, apprised of these kinds of problems as they become evident. Unfortunately, GM failed to implement such a program, ultimately leading to a tragic and costly scandal,” Minsky said.

Also in the auto sector, an enterprise risk management case study of Toyota looked at its problems with unintended acceleration of vehicles from 2002 to 2009. Several studies, including a case study by Carnegie Mellon University Professor Phil Koopman , blamed poor software design and company culture. A whistleblower later revealed a coverup by Toyota. The company paid more than $2.5 billion in fines and settlements.

ERM Case Study: Lululemon

In 2013, following customer complaints that its black yoga pants were too sheer, the athletic apparel maker recalled 17 percent of its inventory at a cost of $67 million. The company had previously identified risks related to fabric supply and quality. The CEO said the issue was inadequate testing. 

Analysts raised concerns about the company’s controls, including oversight of factories and product quality. A case study by Stanford University professors noted that Lululemon’s episode illustrated a common disconnect between identifying risks and being prepared to manage them when they materialize. Lululemon’s reporting and analysis of risks was also inadequate, especially as related to social media. In addition, the case study highlighted the need for a system to escalate risk-related issues to the board. 

ERM Case Study: Kodak 

Once an iconic brand, the photo film company failed for decades to act on the threat that digital photography posed to its business and eventually filed for bankruptcy in 2012. The company’s own research in 1981 found that digital photos could ultimately replace Kodak’s film technology and estimated it had 10 years to prepare. 

Unfortunately, Kodak did not prepare and stayed locked into the film paradigm. The board reinforced this course when in 1989 it chose as CEO a candidate who came from the film business over an executive interested in digital technology. 

Had the company acknowledged the risks and employed ERM strategies, it might have pursued a variety of strategies to remain successful. The company’s rival, Fuji Film, took the money it made from film and invested in new initiatives, some of which paid off. Kodak, on the other hand, kept investing in the old core business.

Case Studies of Successful Enterprise Risk Management

Successful enterprise risk management usually requires strong performance in multiple dimensions, and is therefore more likely to occur in organizations where ERM has matured. The following examples of enterprise risk management can be considered success stories. 

ERM Case Study: Statoil 

A major global oil producer, Statoil of Norway stands out for the way it practices ERM by looking at both downside risk and upside potential. Taking risks is vital in a business that depends on finding new oil reserves. 

According to a case study, the company developed its own framework founded on two basic goals: creating value and avoiding accidents.

The company aims to understand risks thoroughly, and unlike many ERM programs, Statoil maps risks on both the downside and upside. It graphs risk on probability vs. impact on pre-tax earnings, and it examines each risk from both positive and negative perspectives. 

For example, the case study cites a risk that the company assessed as having a 5 percent probability of a somewhat better-than-expected outcome but a 10 percent probability of a significant loss relative to forecast. In this case, the downside risk was greater than the upside potential.

ERM Case Study: Lego 

The Danish toy maker’s ERM evolved over the following four phases, according to a case study by one of the chief architects of its program:

  • Traditional management of financial, operational, and other risks. Strategic risk management joined the ERM program in 2006. 
  • The company added Monte Carlo simulations in 2008 to model financial performance volatility so that budgeting and financial processes could incorporate risk management. The technique is used in budget simulations, to assess risk in its credit portfolio, and to consolidate risk exposure. 
  • Active risk and opportunity planning is part of making a business case for new projects before final decisions.
  • The company prepares for uncertainty so that long-term strategies remain relevant and resilient under different scenarios. 

As part of its scenario modeling, Lego developed its PAPA (park, adapt, prepare, act) model. 

  • Park: The company parks risks that occur slowly and have a low probability of happening, meaning it does not forget nor actively deal with them.
  • Adapt: This response is for risks that evolve slowly and are certain or highly probable to occur. For example, a risk in this category is the changing nature of play and the evolution of buying power in different parts of the world. In this phase, the company adjusts, monitors the trend, and follows developments.
  • Prepare: This category includes risks that have a low probability of occurring — but when they do, they emerge rapidly. These risks go into the ERM risk database with contingency plans, early warning indicators, and mitigation measures in place.
  • Act: These are high-probability, fast-moving risks that must be acted upon to maintain strategy. For example, developments around connectivity, mobile devices, and online activity are in this category because of the rapid pace of change and the influence on the way children play. 

Lego views risk management as a way to better equip itself to take risks than its competitors. In the case study, the writer likens this approach to the need for the fastest race cars to have the best brakes and steering to achieve top speeds.

ERM Case Study: University of California 

The University of California, one of the biggest U.S. public university systems, introduced a new view of risk to its workforce when it implemented enterprise risk management in 2005. Previously, the function was merely seen as a compliance requirement.

ERM became a way to support the university’s mission of education and research, drawing on collaboration of the system’s employees across departments. “Our philosophy is, ‘Everyone is a risk manager,’” Erike Young, deputy director of ERM told Treasury and Risk magazine. “Anyone who’s in a management position technically manages some type of risk.”

The university faces a diverse set of risks, including cybersecurity, hospital liability, reduced government financial support, and earthquakes.  

The ERM department had to overhaul systems to create a unified view of risk because its information and processes were not linked. Software enabled both an organizational picture of risk and highly detailed drilldowns on individual risks. Risk managers also developed tools for risk assessment, risk ranking, and risk modeling. 

Better risk management has provided more than $100 million in annual cost savings and nearly $500 million in cost avoidance, according to UC officials. 

UC drives ERM with risk management departments at each of its 10 locations and leverages university subject matter experts to form multidisciplinary workgroups that develop process improvements.

APQC, a standards quality organization, recognized UC as a top global ERM practice organization, and the university system has won other awards. The university says in 2010 it was the first nonfinancial organization to win credit-rating agency recognition of its ERM program.

Examples of How Technology Is Transforming Enterprise Risk Management

Business intelligence software has propelled major progress in enterprise risk management because the technology enables risk managers to bring their information together, analyze it, and forecast how risk scenarios would impact their business.

ERM organizations are using computing and data-handling advancements such as blockchain for new innovations in strengthening risk management. Following are case studies of a few examples.

ERM Case Study: Bank of New York Mellon 

In 2021, the bank joined with Google Cloud to use machine learning and artificial intelligence to predict and reduce the risk that transactions in the $22 trillion U.S. Treasury market will fail to settle. Settlement failure means a buyer and seller do not exchange cash and securities by the close of business on the scheduled date. 

The party that fails to settle is assessed a daily financial penalty, and a high level of settlement failures can indicate market liquidity problems and rising risk. BNY says that, on average, about 2 percent of transactions fail to settle.

The bank trained models with millions of trades to consider every factor that could result in settlement failure. The service uses market-wide intraday trading metrics, trading velocity, scarcity indicators, volume, the number of trades settled per hour, seasonality, issuance patterns, and other signals. 

The bank said it predicts about 40 percent of settlement failures with 90 percent accuracy. But it also cautioned against overconfidence in the technology as the model continues to improve. 

AI-driven forecasting reduces risk for BNY clients in the Treasury market and saves costs. For example, a predictive view of settlement risks helps bond dealers more accurately manage their liquidity buffers, avoid penalties, optimize their funding sources, and offset the risks of failed settlements. In the long run, such forecasting tools could improve the health of the financial market. 

ERM Case Study: PwC

Consulting company PwC has leveraged a vast information storehouse known as a data lake to help its customers manage risk from suppliers.

A data lake stores both structured or unstructured information, meaning data in highly organized, standardized formats as well as unstandardized data. This means that everything from raw audio to credit card numbers can live in a data lake. 

Using techniques pioneered in national security, PwC built a risk data lake that integrates information from client companies, public databases, user devices, and industry sources. Algorithms find patterns that can signify unidentified risks.

One of PwC’s first uses of this data lake was a program to help companies uncover risks from their vendors and suppliers. Companies can violate laws, harm their reputations, suffer fraud, and risk their proprietary information by doing business with the wrong vendor. 

Today’s complex global supply chains mean companies may be several degrees removed from the source of this risk, which makes it hard to spot and mitigate. For example, a product made with outlawed child labor could be traded through several intermediaries before it reaches a retailer. 

PwC’s service helps companies recognize risk beyond their primary vendors and continue to monitor that risk over time as more information enters the data lake.

ERM Case Study: Financial Services

As analytics have become a pillar of forecasting and risk management for banks and other financial institutions, a new risk has emerged: model risk . This refers to the risk that machine-learning models will lead users to an unreliable understanding of risk or have unintended consequences.

For example, a 6 percent drop in the value of the British pound over the course of a few minutes in 2016 stemmed from currency trading algorithms that spiralled into a negative loop. A Twitter-reading program began an automated selling of the pound after comments by a French official, and other selling algorithms kicked in once the currency dropped below a certain level.

U.S. banking regulators are so concerned about model risk that the Federal Reserve set up a model validation council in 2012 to assess the models that banks use in running risk simulations for capital adequacy requirements. Regulators in Europe and elsewhere also require model validation.

A form of managing risk from a risk-management tool, model validation is an effort to reduce risk from machine learning. The technology-driven rise in modeling capacity has caused such models to proliferate, and banks can use hundreds of models to assess different risks. 

Model risk management can reduce rising costs for modeling by an estimated 20 to 30 percent by building a validation workflow, prioritizing models that are most important to business decisions, and implementing automation for testing and other tasks, according to McKinsey.

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Main article content, organizational risk management practices in time of crisis: an exploratory case study of ethiopian airlines in the corona virus pandemic, g. nekerwon gweh, dejene mamo.

The purpose of this investigative case study research was to scrutinize the approaches of organizational risk management strategies applied by the Ethiopian Airlines throughout the global COVID-19 pandemic. It aimed at assessing and documenting risk management methodologies, best practices and lessons learned by the Airlines to survive the damaging impact the health crisis. The researcher limited the participants to six senior and middle level staff who are responsible to handle the Airlines risk management operations and the project management departments. The Situational Crisis Communication Theory (SCCT) and the Team Leadership Model (TLM) were the conceptual frameworks used as the basis for this study. Data triangulation was used to support the review and analysis of data gathered from various sources. Data analysis methods in conjunction with the NVivo software were used to support the identification of core themes. Situation Awareness and Decision Making, Leadership Presence Strategy, Strategic Internal Communication and Transparent Public Communication were the themes identified. A fundamental finding from the study revealed that Ethiopian Airlines’ Strategic Business Plan calls for the establishment of “multi-business units” as a key principle. This is seen in how the company has diversified its operations into tourism, hospitality and Aviation trainings in addition to the original passenger and cargo services it offers as an airline.

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  • Published: 23 April 2024

Interrater reliability of the violence risk assessment checklist for youth: a case vignette study

  • Anniken L. W. Laake 1 , 2 ,
  • John Olav Roaldset 2 ,
  • Tonje Lossius Husum 1 ,
  • Stål Kapstø Bjørkly 3 ,
  • Carina Chudiakow Gustavsen 4 &
  • Øyvind Lockertsen 1 , 2  

BMC Psychiatry volume  24 , Article number:  303 ( 2024 ) Cite this article

Metrics details

Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12–18 (V-RISK-Y) is a 12-item violence risk screening instrument developed to rapidly identify youth at high risk for violent behavior in situations requiring expedient evaluation of violence risk. The V-RISK-Y instrument was piloted in acute psychiatric units for youth, yielding positive results of predictive validity. The aim of the present study was to assess the interrater reliability of V-RISK-Y in child and adolescent psychiatric units and acute child protective services institutions.

A case vignette study design was utilized to assess interrater reliability of V-RISK-Y. Staff at youth facilities ( N  = 163) in Norway and Sweden scored V-RISK-Y for three vignettes, and interrater reliability was assessed with the intraclass correlation coefficient (ICC).

Results indicate good interrater reliability for the sum score and Low-Moderate-High risk level appraisal across staff from the different facilities and professions. For single items, interrater reliability ranged from poor to excellent.

Conclusions

This study is an important step in establishing the psychometric properties of V-RISK-Y. Findings support the structured professional judgment tradition the instrument is based on, with high agreement on the overall risk assessment. This study had a case vignette design, and the next step is to assess the reliability and validity of V-RISK-Y in naturalistic settings.

Peer Review reports

While evaluations of an individual’s risk for violent behavior were traditionally developed within and for forensic settings [ 1 ], the need for assessing violence risk has been identified in additional settings where management of violent behavior commonly occurs [ 2 , 3 ]. Violence risk assessments are increasingly conducted in multiple contexts of healthcare and other public services [ 3 , 4 ], including mental healthcare [ 2 ] and emergency departments [ 5 , 6 ]. As the settings in which violence risk assessments are utilized expand, the need emerges for tools tailored to target populations and the evaluation of their psychometric properties.

Institutions providing healthcare and social services for youth commonly face challenges related to aggression and violence. In youth psychiatric units, inpatient violence is a substantial concern, negatively impacting the wellbeing of both patients and staff [ 7 ]. For instance, a chart review study in an inpatient psychiatric unit for adolescents showed that aggressive or violent behavior requiring intervention were recorded for 28.4% of inpatients [ 8 ]. Further, child protective services (CPS) is identified as one of the public services at highest risk of encountering violent behavior from youth [ 9 ]. Thus, these are settings with a need for available resources to identify, prevent and manage violence risk. The ability to accurately identify individuals at high risk for violent behavior facilitates implementation of interventions to prevent violence from occurring [ 4 , 10 , 11 , 12 ], and aids decision-making related to patient treatment [ 13 , 14 ]. Further, routinely assessing violence risk in inpatient psychiatric settings can help de-escalate aggressive behavior [ 15 ] and can reduce use of coercive measures, promoting a safer environment for patients and staff [ 16 , 17 , 18 , 19 ].

Violence risk assessments for youth

For children and adolescents, assessing violence risk require distinct situational and intrapersonal considerations (e.g. school setting; caretaker situation; cognitive developmental stage; psychiatric diagnostics), and assessments for adults can not readily be generalized to youth [ 1 , 20 ]. Violence risk assessment tools specifically for youth have been developed and validated for various settings, with the Structured Assessment of Violence Risk in Youth (SAVRY) [ 21 ] and Youth Level of Service/Case Management Inventory (YLS/CMI) [ 22 ] among the most commonly researched [ 23 , 24 ]. These instruments are comprehensive, time consuming to administer, and may require specific training to utilize [e.g. 25 , 26 ]. In facilities commonly required to make judgments about violence risk, such as emergency departments and acute psychiatric institutions, structural and contextual aspects like scarcity of time and staff resources influence the ability to routinely conduct in-depth violence risk assessments [ 27 , 28 ].

For adults, several shorter violence risk screeners, such as V-RISK-10 [ 29 ], have been designed to rapidly identify individuals at high risk for violence. In situations where comprehensive assessments are not feasible, these brief instruments can be used to quickly identify high-risk individuals and guide initial decisions about the need for more comprehensive risk assessments or implementation of immediate interventions [ 30 , 31 ]. However, in comparison to adult populations, the development of violence risk screening instruments for youth is lagged. In lieu of available instruments tailored to youth, providers have in some instances used tools designed for adult populations, such as V-RISK-10 [ 32 ].

Violence risk assessment checklist for youth aged 12–18 (V-RISK-Y)

The V-RISK-Y is a violence risk screening tool for youth aged 12 to 18, based on the V-RISK-10 screener. The instrument is designed to be time-efficient, self-explanatory, and possible to use without prior training [ 32 ]. As such, it caters to institutions providing 24-hour care, where acute evaluations are conducted, and where staff trained in risk assessment may not readily be available.

V-RISK-Y was piloted in an emergency psychiatric unit for youth in Norway [ 32 ]. Results indicated good predictive validity for violent events during the youth’s hospital stay, with Area Under the Curve of the Receiver Operating Characteristics (AUC) of a high value of 0.762 for the sum score of V-RISK-Y. Interrater reliability for V-RISK-Y was assessed in the pilot by scoring of case vignettes. As measured by intraclass correlation coefficient (ICC), interrater reliability for individual items was poor to fair, and the ICC for the sum score was 0.51. The pilot version of V-RISK-Y included relevance scores for each of the 12 items, but as the relevance scores were perceived as confusing by participants it was hypothesized that they contributed to low ICC values [ 32 ]. Because V-RISK-Y is a new instrument, there is a need to establish psychometric properties of the screening in relevant settings and with a larger sample size.

  • Interrater reliability

While knowledge about interrater reliability is essential for evaluating the validity of a scale, reporting of interrater reliability in psychometric studies is commonly neglected [ 33 ]. For violence risk assessment, concordance between participants in assessing violence risk has been associated with predictive validity [ 34 ]. McNiel and colleagues (2000) assessed interrater reliability and predictive validity for risk assessments in an inpatient psychiatric unit and found that predictive validity of assessed risk significantly improved with agreement between participants.

Previous studies on interrater reliability for violence risk assessments have commonly utilized the interrater correlation coefficient (ICC) as reliability measure [e.g. 29 , 35 , 36 ], which indicates the variation between raters measuring the same individuals [ 37 ]. A study on V-RISK-10 assessed interrater reliability in an in-patient psychiatric setting, and included ratings for 73 acute psychiatric patients from 25 participants [ 29 ]. ICC values indicated good interrater reliability for the sum score, fair for the Low-Moderate-High risk level, and for single items ICC ranged from poor to good [ 29 ]. In a systematic review of psychometric properties of violence risk assessments for youth, ICC estimates for SAVRY and YLS/CMI indicated fair to excellent interrater reliability across published studies [ 38 ]. Given the lack of established violence risk screening instruments for youth, interrater reliability of violence risk screeners for youth has not been assessed other than in the V-RISK-Y pilot study.

The main objective of the present study was to assess the interrater reliability of V-RISK-Y in facilities where youth receive psychiatric in- and outpatient care, as well as acute child protective services institutions. A secondary aim was to assess whether there are differences in interrater reliability between types of youth facilities, or between types of staff in these institutions.

Design, setting and participants

This study was designed as a case vignette study, where staff from mental health and child protective services ( N  = 163) rated V-RISK-Y for three written cases. Vignettes simulate real life and allows for controlling included variables, ensuring all participant responses are based on the exact same information [ 39 ]. The design circumvents ethical and practical challenges which commonly arise when including vulnerable individuals in research [ 40 ], and thus is beneficial for initial assessment of an instrument. Generalizability is one of the major criticisms of this methodology as the complexities of real life can be difficult to capture in a written scenario [ 39 , 40 ].

Participants were recruited among staff from youth facilities participating in an ongoing V-RISK-Y multicenter study in Norway and staff from youth psychiatric units participating at a V-RISK-Y seminar in Sweden. Ethical approval was granted by the Regional Committee for Medical and Health Research Ethics (REK ID: 218444).

Sample characteristics are illustrated in Table  1 . Participants included psychologists ( n  = 15), physicians ( n  = 18), as well as staff members with other professions ( n  = 106). Staff other than physicians and psychologists consisted of professions that do not require postgraduate education, including nurses, social workers, social educators, and youth workers. Only staff in direct contact with youth were included (i.e. administrative staff was not included).

The Norwegian youth facilities consisted of four acute psychiatric units ( n  = 72) providing in-patient services, and four acute child protective services (CPS) institutions ( n  = 52) providing residential care. CPS institutions are custodial institutions for acute placement of youth without satisfactory home conditions [ 41 ], and staff at these institutions largely consist of social workers and youth workers.

Participants from Sweden included staff from six child and adolescent psychiatric units ( n  = 39). These units consisted of facilities providing outpatient mental health services as well as units for inpatient acute psychiatric care for children and adolescents.

Measures consisted of printed copies of V-RISK-Y and three case vignettes. Materials were developed in Norwegian and translated to Swedish in collaboration with Swedish mental health professionals.

V-RISK-Y consists of 12 items: V1) Prior and/or current acts of violence; V2) Prior and/or current threats of violence; V3) Prior and/or current alcohol or substance abuse; V4) Prior and/or current severe symptoms of mental health disorders; V5) Disruptive, impulsive behaviour/Behavioural disorder; V6) Poor insight into the mental disorder and/or behaviour; V7) Suspicion; V8) Demonstrates lack of empathy; V9) Unrealistic planning; V10) Future stressful situations; V11) Prior and/or current severe trauma; and V12) The youth and parents/guardians’ perception of risk. Each item is rated according to their presence as “No”, “Moderate/Maybe”, “Yes”, or “Don’t Know”. The level of violence risk, “Low”, “Moderate”, or “High” is categorically indicated by the rater based on item scores combined with clinical judgment, following the structured professional judgment (SPJ) tradition [ 42 ]. The relevance scores previously included are removed from the current version. If feasible, the screening should be scored interdisciplinary. It is recommended to do the scoring upon the initial contact with the youth, such as after the intake interview, without the youth or their parents/guardians present.

The case vignettes were each approximately one page. Vignette summaries are included in Appendix 1. Cases were developed by clinicians and researchers experienced in violence risk assessment and youth psychiatry, and designed to reflect cases commonly encountered in youth psychiatric units and CPS institutions. While no psychiatric diagnoses were specified or fully described in the cases, the description of Case 1 (Farhad) alludes to autism specter disorder, Case 2 (Peter) describes antisocial behavior and symptoms of behavioral disorders, and Case 3 (Jeanette) indicates a depressive reaction. To reflect a clinical setting where information about youth might be lacking at intake, each case was designed with incomplete information to allow for the “don’t know” response to be an appropriate score for some items.

Researchers visited each youth facility interested in participating and gave an introduction of the development and structure of V-RISK-Y. Because V-RISK-Y is designed to be self-explanatory, no in-depth training in scoring the instrument was provided. Staff who agreed to participate were given writeups of the cases and V-RISK-Y forms and asked to independently rate each case to the best of their ability in one sitting. Ratings were conducted anonymously, without the researchers present. While no specific time limit was given for rating the cases, participants typically spent a total of 15 to 30 min completing the scorings.

Statistical analyses

Statistical analyses were conducted in Stata Statistical Software 17.0. Statistical significance level was set to 0.05 for all levels. Interrater reliability was assessed by estimating the intraclass correlation coefficient (ICC) for the 12 V-RISK-Y individual items, the sum score, and the risk level (Low-Moderate-High). ICC values range from 0 to 1, and interrater reliability is typically interpreted as low for values below 0.50, moderate for values between 0.50 and 0.75, good for values between 0.75 and 0.90, and excellent for values above 0.90 [ 37 ]. Because of clustering of data due to shared environmental and individual factors among participants, ICC was estimated based on multilevel statistical models which account for homogeneity [ 43 ], using the estat icc command.

The risk level was scored on an ordinal scale, as Low (1), Moderate (2) and High (3). V-RISK-Y items were also interpreted on an ordinal scale as “No” (0), “Don’t Know” (1), “Moderate/Maybe” (2), and “Yes" (3). “Don’t know” ratings were weighted as 1 and included in item analyses, which was also the method for analyses in the recent pilot study on V-RISK-Y [ 32 ]. Accounting for their ordinal properties, ICC for these variables was calculated based on multilevel ordered logistic regression [ 44 ]. For the sum score variable (range 0–36), mixed linear regression was used to estimate ICC [ 45 ].

Analyses were conducted for the overall data, and stratified analyses were conducted for type of institution and type of profession. As there is overlap in responsibilities of psychologists and physicians in the participating facilities, these professions were combined and compared to the other professions to increase statistical power.

For ten submitted forms, the full V-RISK-Y scoring was missing, and these ratings were excluded. All ten excluded ratings were for Case 3, Jeanette. There were no more than three missing values for any included V-RISK-Y ratings. Given the low number of missing scores in the included ratings, as displayed in Table  2 , missing values were not replaced.

Table 2 shows the frequency of scores for each V-RISK-Y item by case. The mean sum score for the cases was 24.43 [SD = 2.74] for Case 1, 27.99 [SD = 3.12] for Case 2, and 16.15 [SD = 5.00] for Case 3.

Results for analyses of interrater reliability for the overall data and stratified analyses for the types of youth facilities are presented in Table  3 . For the overall data, interrater reliability is excellent for V1 (Violence), good for V2 (Threats), moderate for V3 (Substance abuse), poor for V4 (Severe mental health symptoms), moderate for V5 (Disruptive behavior), good for V6 (Insight), poor for V7 (Suspicion), good for V8 (Empathy), moderate for V9 (Unrealistic plans) and V10 (Future stress), good for V11 (Trauma) and poor for V12 (Own perception). ICC estimates remained identical when type of institution and profession was controlled for in the mixed model. For stratified analyses, confidence intervals are wide and overlapping for all individual items.

Interrater reliability for types of youth facilities

Interrater reliability is good for V-RISK-Y sum score, and excellent for the Low-Moderate-High risk level across type of facility. For the acute psychiatry group, interrater reliability is excellent for V1, good for V2, moderate for V3, poor for V4, good for V5, moderate for V6, poor for V7, good for V8 and V9, moderate for V10, good for V11, and poor for V12.

For the CPS institutions, interrater reliability is excellent for V1 and V2, good for V3, poor for V4, moderate for V5 and V6, poor for V7, excellent for V8, moderate for V9, poor for V10, good for V11, and poor for V12.

For the Swedish units, interrater reliability is good for V1, excellent for V2, moderate for V3, poor for V4, good for V5, excellent for V6, poor for V7, excellent for V8, good for V9, moderate for V10, good for V11, and moderate for V12.

Interrater reliability for professional groups

Results for interrater reliability for the professional groups are presented in Table  4 .

Across the professional groups, interrater reliability is good for the sum score and excellent for the Low-Moderate-High risk level. For the physician/psychologist group, ICC values did not compute for items V1 and V8. Interrater reliability is excellent for V2, moderate for V3, poor for V4, excellent for V5 and V6, poor for V7, excellent for V9, moderate for V10, excellent for V11, and moderate for V12.

For the other professions, interrater reliability is excellent for V1 and V2, moderate for V3, poor for V4, moderate for V5 and V6, poor for V7, excellent for V8, moderate for V9, poor for V10, moderate for V11, and poor for V12.

Results indicate overall good interrater reliability for V-RISK-Y, and moderate to good interrater reliability for most individual items. These findings are comparable to interrater reliability for other youth violence risk assessments tools [ 38 ], as well as for V-RISK-10 [ 29 ], a recommended violence risk screener for adults utilized internationally [ 31 ]. There were few differences in interrater reliability between the youth facilities included in the study, which is promising for the potential utility of V-RISK-Y across settings where violence risk screening of youth is needed. No major differences in interrater reliability were found between Swedish and Norwegian units, implying that the level of agreement between staff at youth facilities in Sweden and Norway is similar.

Sum score and risk level

The interrater reliability for the sum score is consistently high, indicating agreement between participants on the sum of present risk factors presented in the cases. Results indicate good interrater reliability for the sum score of V-RISK-Y, and excellent for the Low-Moderate-High risk level across all types of facilities. Similarly, interrater reliability for the sum score is good, and excellent for the Low-Moderate-High risk level across the professional groups. These results are encouraging, as it indicates that there is overall agreement on the risk level assigned to the cases based on the V-RISK-Y scoring. These results lend support to the SPJ tradition in which V-RISK-Y is developed, demonstrating high agreement of the discretionary risk assessment guided by scoring the instrument [ 46 ].

Single items

For most single items, interrater reliability is consistently moderate to good across all groups. For items representing static risk factors, such as V1 (Violence) and V2 (Threats), interrater reliability is good to excellent. For V3 (Substance abuse), interrater reliability is good for CPS institutions while moderate for the other types of facilities. These items are likely relatively easy to score provided the availability of relevant information.

The poorest interrater reliability is found for V4 (Severe symptoms of mental health disorder), where ICC is close to zero across all groups. In the V-RISK-Y pilot study, which also assessed interrater reliability with case vignettes, the ICC value of 0.66 for V4 indicates moderate interrater reliability [ 32 ]. Characteristics of the case vignettes could provide one possible explanation of the low reliability measure for this item. Few typical symptoms of mental health disorders were described in the cases, and there was no mention of previous or current psychiatric diagnoses. The first case of Farhad describes a condition that could be compatible with autism specter disorder, where challenges in communication and social interactions are highlighted. For the second case, Peter, behavioral issues are the most prevalent. The third case of Jeanette describes symptoms that can be seen as a depressive reaction, where a change in mood and behavior has occurred following negative experiences. Another explanation for discrepant findings of interrater reliability for V4 could be that the scoring instructions are unclear or too broad. For V-RISK-10, interrater reliability for V4 was good, with ICC value of 0.70 for single measures and 0.83 for average measures [ 29 ]. It is possible that this item is harder to score for youth than it is for adults. The pilot study [ 32 ] and the V-RISK-10 study [ 29 ], which both found higher ICC values for V4, were conducted in acute psychiatric inpatient units only. In this study, interrater reliability was not higher for the acute psychiatric units as compared to the other youth facilities, so the differences cannot readily be explained by differences in types of institutions. The V-RISK-10 study was conducted in a naturalistic setting, and the discrepancies between these findings could imply difficulties in scoring this item for a vignette as compared to in-person cases. However, another V-RISK-10 study assessing interrater reliability through a case vignette design with 15 vignettes and eight raters yielded similar results [ 13 ].

Interrater reliability for item V7 (Suspicion) was poor across all groups. The description of V7 is largely based on exhibited behavior, which can be difficult to judge from a vignette without relying on behavioral observations. In the V-RISK-Y pilot, however, interrater reliability for this item was good, with an ICC estimate of 0.76 [ 32 ].

Interrater reliability is moderate for V10 (Stress exposure) for all types of facilities, except for the CPS institutions where it is poor. Further, interrater reliability for V10 is lower for professions other than psychologists and physicians. It is possible that these differences could reflect that staff groups have different ways of assessing stressful situations. Physicians and psychologists in the psychiatric units are typically responsible for treatment, whereas other staff groups are more present in the institutional environment outside of treatment sessions. These findings could also be impacted by most staff from the other professions group being from the CPS institutions. Possibly, staff in psychiatric units for youth have different ways of assessing stressful future situations as compared to CPS staff. Differences in ways of thinking about future stress may for instance be due to institutional characteristics, where the relatively closed environment of an inpatient unit might be perceived as mitigating stressful situations as compared to a more open residential setting. Interrater reliability for this item was good (ICC = 0.76) in the pilot study [ 32 ], which was conducted in a psychiatric unit.

For V12 (User perception), one of the items novel to V-RISK-Y, interrater reliability was poor to moderate for all groups. This finding is comparable to the pilot study, where ICC for this item was 0.35 [ 32 ]. This item was included in V-RISK-Y based on findings that patients’ own perception of violence risk is significantly associated with actual risk [ 47 ]. Patients’ own perception is not commonly included in existing screenings and assessments of violence risk [e.g. 48 ], and potentially represents a new way of thinking about risk assessments which may make it difficult to score. Further, this item is challenging to score based on the provided case vignettes, where there was little information about the youth or parents’ perceived risk of violence. A study conducted in a naturalistic setting, where the youth and their guardians could be asked about risk perception, might yield better interrater reliability for this item.

In the V-RISK-10 study where interrater reliability was assessed in a naturalistic setting, some items were found to have poor interrater reliability, including item V7 (Suspiciousness) and V10 (Future stressful situations). However, in subsequent research on predictive validity of V-RISK-10, items with low interrater reliability were still found to have high predictive validity [e.g. 49 , 50 ], and the items are kept in the instrument. Before deciding what to do with items with low interrater reliability, results from this study must be seen in relation to findings from ongoing efforts to validate V-RISK-Y, and be compared to items’ contribution to predictive validity of the instrument.

Limitations and future research.

There are some limitations in the study design that may have impacted results, which should be considered in future research on psychometric properties of V-RISK-Y. The case vignette design allows to control for the information provided to score each case. However, while efforts were made to design vignettes resembling clinical cases, a case vignette design does not reflect a naturalistic setting. Only a narrow range of scenarios are represented in the included vignettes, which do not cover complexities and diversity of real-life contexts. These limitations impact the generalizability of the findings to settings outside of theoretical case scorings. Case vignettes are commonly used in violence risk assessment trainings for skill development [e.g. 51 , 52 ]. It is possible that the cases would be better suited for a training purpose than realistic assessment of interrater reliability. Nevertheless, the good interrater reliability found for the sum score and the Low-Moderate-High risk level lend support for continuing research efforts on the current version of V-RISK-Y. It would also be of interest to conduct a naturalistic study of interrater reliability as was done for V-RISK-10.

Demographic information about participating staff was not collected in the present study. Thus, findings cannot be interpreted in relation to demographic variables such as work experience, age or sex. These variables should be included in future research to enable more distinguished comparisons between included staff groups, which particularly would be of interest because V-RISK-Y is developed to be easy to use for all clinical staff.

The design of this study included only three cases and a high number of participants. In studies with low between-rater variance, which may be the case when all participants are in similar work environments, precision of ICC is facilitated by a high number of raters and a low number of cases [ 53 ]. It is likely that the large confidence intervals for the estimated ICC values and the inability to compute ICC for some items in the stratified analyses on profession reflects the design of a high rater to case ratio. A study with a different setup, where more cases are scored by fewer participants, could mitigate this issue and allow for further assessment of discrepancies in interrater reliability found in stratified analyses.

In this study, cases were scored individually by the participants. The recommendation for V-RISK-Y is interdisciplinary rating when possible. Further research should assess whether interdisciplinary versus individual scoring influences the psychometric properties of V-RISK-Y. In this study, as well as in the pilot, “Don’t know” scores are coded as 1 and included in the ordinal scale of the single items, based on findings on V-RISK-10 showing that don’t know scores should be counted toward risk [ 54 ]. To date, there is no research exploring whether the same argument holds true for V-RISK-Y, which should be assessed in future studies.

Results from this initial study on interrater reliability for V-RISK-Y are promising. While poor interrater reliability was found for some of the risk items, the overall agreement on sum of present risk factors and risk level is high. Findings indicate acceptable interrater reliability for V-RISK-Y across different types of youth facilities where the objective of identifying violence risk commonly occur, namely acute psychiatry, outpatient psychiatry, and child protective services. Given limitations in the study design, findings should be cautiously interpreted, and generalizability to naturalistic settings cannot be readily assumed. This is the first interrater reliability study of the current version of the V-RISK-Y, and an important step in establishing the psychometric properties of this instrument. Research on V-RISK-Y is still in its early stages, and there is a need for further studies to assess its psychometric properties in naturalistic settings.

Data availability

The datasets analyzed in the current study are not publicly available and cannot openly be shared due to privacy laws and restrictions in ethical approval. Data are available from the authors upon reasonable request.

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Acknowledgements

We are truly grateful for the indispensable statistical support provided by Professor Emeritus Petter Laake of the University of Oslo, Faculty of Medicine, Department of Biostatistics. Staff at all participating institutions in Norway and Sweden are thankfully acknowledged for their contributions to data collection and administration of the study.

The study is funded by Oslo University Hospital and Oslo Metropolitan University.

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ØL and JR were responsible for data collection. ØL, JR, CG, and SB contributed to developing the case vignettes used in the study. AL performed the data analysis and drafted the original manuscript. All authors contributed substantially to the content and revising of the manuscript.

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Appendix: case vignettes

Case 1: farhad [ 15 ].

Farhad is referred for assessment of behavioral disorder. He struggles with schoolwork and in social interactions with peers. As a young child (6–8 years), he kicked and hit his peers, without anyone getting physically hurt. At 13, he attacked a teacher who suggested he received special education, resulting in the teacher sustaining a concussion. He is easily upset, particularly if he feels misunderstood, devalued, or struggles to express himself. At home, he spends most of his time in front of the computer. During initial contact, he seems disinterested in engaging in conversation, and is annoyed when staff asks him questions. Peers are uneasy around him. He does not understand that others get upset when he hits or kicks them, and says it’s their fault for treating him unfairly.

Case 2: Peter [ 17 ]

Peter struggles to adhere to rules and structure and demonstrates lack of respect for authorities. In school, he once lifted a teacher out of the classroom and locked the door. At home he is aggressive and destructive, and his parents often give in to what he wants out of fear that he will destroy things or hurt them. Peter describes his parents as weak. He does not get along with his peers, but has a few younger friends. He stays out late, and drinks alcohol on the weekends. He recently physically assaulted someone for calling him gay. He wants to move out from his parents house and become rich.

Case 3: Jeanette [ 15 ]

Jeanette has always been ambitious in school, but lately she’s been reluctant to go to school and her grades have dropped. Upon her parents’ separation one year ago, Jeanette started spending less time at home and started going to the mall. A few weeks ago she got drunk with her friends, and was the victim of an attempted rape. She did not tell her parents about this incident. She is normally good with her younger siblings, but recently she yelled at her little brother when he entered her room and threatened to hit him. Her mother has noticed that Jeanette has started self-harming by cutting her wrists. In the initial contact, she seems resigned, and lets her mother answer for her.

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Laake, A.L.W., Roaldset, J.O., Husum, T.L. et al. Interrater reliability of the violence risk assessment checklist for youth: a case vignette study. BMC Psychiatry 24 , 303 (2024). https://doi.org/10.1186/s12888-024-05746-8

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This study aims to explore the optimal management strategy for pediatric vanishing testes syndrome (VTS) based on pathological characteristics. We retrospectively analyzed clinical data and pathological results of children with unilateral VTS who underwent surgical treatment at our center from July 2012 to July 2023. The children were categorized into the testicular excision group and testicular preservation group based on the surgical approach. Clinical characteristics and outcomes were compared between the two groups. Pathological examination results of excised testicular tissues were collected and analyzed, and long-term follow-up was conducted. A total of 368 children were included in this study. The age of the children at the time of surgery was 27 months (range, 6–156). Among them, 267 cases (72.6%) had VTS on the left side, and 101 cases (27.4%) on the right side. There were no statistically significant differences (P > 0.05) in age, affected side, contralateral testicular hypertrophy (CTH), testicular location, and preferred surgical incision between the testicular excision group (n = 336) and the testicular preservation group (n = 32). In the preservation group, two children experienced scrotal incision infections, showing a statistically significant difference compared to the excision group (P < 0.05). Pathological examination of excised tissues revealed fibrosis as the most common finding (79.5%), followed by vas deferens involvement (67%), epididymis involvement (40.5%), calcification (38.4%), and hemosiderin deposition (17.9%). Seminiferous tubules (SNT) was present in 24 cases (7.1%), germ cells (GC)in 15 cases (4.5%), and ectopic adrenal cortical tissue(EACT) in 1 case (0.3%). VTS belongs to a type of non-palpable testes (NPT) and requires surgical exploration. Considering the risk of scrotal incision infection after preserving atrophic testicular remnants and the unpredictable malignant potential, we recommend excision.

Introduction

Cryptorchidism or undescended testis is one of the most common congenital anomalies in male newborns, with an incidence of 1.0–4.6% in full-term infants and up to 45% in premature infants 1 . For ease of surgical management, clinical practice often categorizes testes as palpable or non-palpable, with approximately 20% falling into the non-palpable category 2 . Vanishing testes syndrome (VTS) is one of the reasons of non-palpable testes (NPT) in children, characterized by the discovery of blind-ended spermatic vessels or nodules with unidentifiable normal testicular morphology during surgical exploration 1 , 2 , 3 . However, consensus on the optimal diagnostic and therapeutic approaches for VTS remains elusive. Some scholars previously advocated for surgical excision of testicular remnants, positing that residual testicular tissues may harbor germ cells (GC) and seminiferous tubules (SNT) with potential malignant transformation risks 4 , 5 . Nevertheless, recent research has presented an alternative perspective, suggesting that excision may not be imperative, given the relatively low incidence of GC and SNT, coupled with insufficient robust evidence indicating a continued presence of GC and SNT leading to potential malignant risks 3 , 6 . To delve further into this matter, the current study conducts a retrospective analysis of clinical and pathological data from 368 cases of unilateral VTS treated at our center over the past 11 years, aiming to provide additional data support for the diagnosis and treatment of VTS.

Materials and methods

We conducted a retrospective analysis of case data for children with unilateral VTS who underwent surgical treatment at our center from July 2012 to July 2023, utilizing the electronic medical records system. Inclusion criteria comprised initial diagnosis of cryptorchidism, with surgical confirmation of blind-ended spermatic vessels or identification of atrophic nodules during exploration. Exclusion criteria encompassed a history of surgery on the affected side for undescended testis, testicular torsion, or incarceration related to inguinal hernia, all of which could lead to an NPT. A detailed dataset was constructed by carefully reviewing clinical records, surgical records, and pathological data for each patient.

Preoperative ultrasound and definition of testicular hypertrophy

All patients underwent preoperative ultrasound examination of the scrotum or inguinal region to detect NPT. Simultaneously, the maximum longitudinal diameter of the contralateral testis was measured to assess whether it was hypertrophic. We utilized a criterion of 1.6 cm for testicular diameter in patients under 36 months as the threshold for defining testicular hypertrophy 3 , 7 .

Surgical management

Prior to the commencement of surgical exploration, a thorough physical examination was conducted under general anesthesia to ensure that the patients met the inclusion criteria. If palpable cord-like tissue or atrophic remnants are detectable in the inguinal or scrotal region, inguinal or scrotal incision exploration is the preferred approach. If no structures are palpable, or if there is contralateral inguinal hernia present, laparoscopic exploration is the first choice. During laparoscopic exploration, if no intra-abdominal testis is found, and the spermatic cord enters the closed internal ring, exploration of the inguinal or scrotal region is performed. At the distal end of the spermatic cord, a small fibrotic remnant is identified, with no visible normal testicular tissue. If macroscopically abnormal intra-abdominal testicular remnants are discovered during laparoscopic examination, we advocate for their removal. During the procedure, communication with the parents was reiterated to inform them about the testicular development, and based on parental choice, patients were categorized into the testicular excision group or preservation group. All excised residual specimens underwent histological examination with hematoxylin and eosin (H&E) staining.

Statistical analysis

Statistical analyses were performed using SPSS Statistics, version 25.0 (IBM Corp., Armonk, NY, United States). Continuous variables were presented as mean ± standard deviation (SD) or mean (min–max), and categorical variables were presented as n (%). Comparisons were made using chi-squared or Fisher’s exact tests for categorical variables. All tests were two-tailed. A significance level of P  < 0.05 was considered statistically significant.

Ethical approval

This study obtained approval from the Ethics Committee of Anhui Provincial Children’s Hospital (Approval No. 116123S21), ensuring the privacy and confidentiality of all data. Patient participation was voluntary, and informed consent was obtained from parents prior to their children’s involvement, documented through signed informed consent forms. All the procedures involving human participants followed in the study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

This study included a total of 368 pediatric patients with VTS. The mean age of the patients at the time of surgery was 27 months (range, 6–156). Among them, 267 cases (72.6%) had VTS on the left side, and 101 cases (27.4%) on the right side. Thirty-three cases were concurrently associated with contralateral undescended testis or inguinal hernia. Color Doppler ultrasound revealed atrophic nodules in 102 cases (27.7%), with 16 located in the inguinal region and 86 within the scrotum. In 263 cases (71.5%) of patients under 36 months, 172 cases (65.4%) exhibited contralateral testicular hypertrophy (CTH), with ultrasound longitudinal diameters exceeding 1.6 cm. A total of 206 cases (56%) opted for laparoscopic exploration, including 18 cases with contralateral inguinal hernia. The remaining 162 cases (44%) preferred inguinal or scrotal incision exploration.

Based on parental choices during surgery, 336 patients chose testicular excision, while the remaining 32 opted for testicular preservation. Comparative analysis of data between these two groups, including patient age, affected side, CTH, testicular position, and preferred surgical incision, showed no significant differences ( P  > 0.05) in these aspects (Table 1 ). However, it is noteworthy that in the preservation group, two cases, aged 22 months and 30 months respectively, experienced scrotal incision infections postoperatively, showing statistical significance ( P  < 0.05). All patients did not undergo contralateral testicular orchidopexy.

Figure  1 illustrates an atrophic nodule retrieved from the left inguinal incision, where the spermatic vessels and vas deferens were absent, replaced by fibrotic strands (Fig.  1 ). Excision and pathological examination were performed. Results from H&E staining revealed fibrosis in 267 cases (79.5%), vas deferens involvement in 225 cases (67%), epididymis involvement in 136 cases (40.5%), calcification in 129 cases (38.4%), and hemosiderin deposition in 60 cases (17.9%) (Fig.  2 ). Multiple pathological components were found in 83.9% (282/336) of the excised tissue in the excision group. Additionally, 24 specimens (7.1%) showed the presence of SNT, while 15 specimens (4.5%) exhibited GC. Furthermore, one specimen revealed ectopic adrenal cortical tissue (EACT) (Fig.  3 ). An atrophic nodule retrieved from the left scrotal incision, showing the presence of spermatic vessels and vas deferens but lacking normal testicular parenchyma. After consulting with the parents, the remnant was preserved (Fig.  4 ).

figure 1

Atrophic nodule extracted via left inguinal incision.

figure 2

The pathological composition of VTS.

figure 3

The pathological microscopic images of the excised tissue with H&E staining, captured under a × 200 magnification. ( A ) Ectopic adrenal cortex components are observed adjacent to the epididymal duct. ( B ) Iron-hemosiderin deposition and calcification are visible within the fibrous tissue. ( C ) Large and primitive germ cells are seen between the supporting cells of convoluted seminiferous tubules. ( D ) Underdeveloped, small convoluted seminiferous tubules.

figure 4

Atrophic nodule retrieved from the left scrotal incision.

Through outpatient follow-up examinations, with an average follow-up time of 40 months (range, 3–120), no abnormal development or testicular torsion was observed in the contralateral testis. Among the 32 patients in the preservation group, ultrasound examinations did not detect any malignant transformations, and no cases required secondary surgical excision.

Currently, the guidelines of the European Association of Urology categorize undescended testes into palpable and non-palpable types for clinical management. Among the 20% of NPT, 50–60% are intra-abdominal, canalicular, or peeping (right inside the internal inguinal ring), while the remaining 20% may be absent, 30% atrophied or underdeveloped, and sometimes include cases of ectopic testicles 1 . A retrospective review of clinical cases reveals that VTS is the fundamental cause in 35–69% of clinically NPT 8 , 9 , 10 . Therefore, some scholars consider that VTS is one of the reasons for the inability to palpate the testicle and recommend explaining this to all patients and their families before surgery 10 .

Due to the lack of consensus, various definitions of VTS exist in the literature 3 , 4 , 5 , 11 , 12 . The common feature is the presence of NPT, with only residual structures detected during surgical exploration. In this study, we adopt the definition of VTS as a congenital disease where normal testicular tissue is not identifiable by the naked eye after clinical exploration of the NPT 3 , 6 , 13 . This includes the presence of testicular remnants, nodules, or tissues adjacent to the testis/testicular side at the end of the spermatic cord. Although the etiology, pathological tissue composition, and prognosis of VTS may differ from those of surviving undescended testes 5 , 6 , VTS is considered a result of prenatal or late gestational vascular thrombosis, torsion, or endocrine abnormalities 5 . However, recent studies strongly support the theories of vascular accidents and prenatal torsion, rather than endocrine diseases 14 . Our study consistently observes and supports this theory, as fibrosis, malnutrition-induced calcification, hemosiderin deposition, and the presence of macrophages in the excised residual tissues indicate vascular accidents 4 , 15 , 16 . Additionally, VTS is more common on the left side, as reported in previous studies 3 , 4 , 5 , 6 , 16 . He et al. 16 suggest that it is challenging to explain this significant lateralization with endocrine factors. The potential reasons include anatomical relationships between the left testicular vein and the left renal vein, leading to vascular occlusion secondary to abnormal renal activity 5 . Furthermore, the earlier descent of the left testis during fetal development may be another contributing factor 15 , 16 .

Preoperative imaging examinations are unable to determine the presence of the testes 17 . Although ultrasound is a non-invasive tool, it is time-consuming, expensive, and lacks accuracy in detecting the presence or location of intra-abdominal testes in non-palpable cases 1 , 18 . However, Press et al. 19 found that ultrasound can detect 84.8% of NPT, including 12.1% with atrophic nodules. These results can impact surgical planning, avoiding unnecessary laparoscopic explorations. In our study, ultrasound is cost-effective (approximately $13), and all patients underwent preoperative ultrasound examinations. The ultrasound results revealed 102 cases (27.7%) with atrophic nodules, including 16 cases in the inguinal region and 86 cases in the scrotum. When ultrasound cannot detect the testes, parents are informed of various possibilities and corresponding treatment methods for the presence of NPT. Another essential role of ultrasound is detecting CTH. Unlike measuring tools such as calipers, ultrasound can exclude interference from the epididymis, scrotal skin, and adjacent soft tissues during the measurement, making it considered the best tool for assessing testicular size in the pediatric population 20 . Although CTH often indicates ipsilateral testicular atrophy, ultrasound is often challenging in determining the location of atrophic nodules 16 . Therefore, CTH has no impact on the decision-making for NPT management, consistent with the results of Wei et al. 21 . Another study’s findings indicate that regardless of ultrasound results, over 80% of surgeons choose laparoscopic exploration as the initial step in diagnosing and treating NPT, while less than 20% of participants opt for inguinal/scrotal approaches as the primary choice for NPT. Supporters of this approach believe that, as only 14–32% of patients have an intra-abdominal testis, this incision allows for easier detection of the testis, potentially avoiding the need for laparoscopic exploration 22 . However, if there is suspicion of a nodular lesion on the same side and CTH is present on the contralateral side, the option of scrotal incision and excision of the nodule can be considered to confirm testicular disappearance, thus obviating the need for laparoscopic exploration 1 . In our study, 206 cases (56%) of patients who did not initially exhibit cord-like structures or atrophic remnants in the inguinal or scrotal region underwent initial laparoscopic exploration. Additionally, 162 cases (44%) with detected nodules in the inguinal or scrotal region underwent direct inguinal or scrotal exploration and residual excision. This surgical approach is considered to have potential certainty for the diagnosis and treatment of testicular disappearance 23 .

Past studies have debated whether atrophic testicular nodules need to be excised. Unlike undescended testes, congenital undescended testes increase the risk of future malignancies 24 . However, the etiology of VTS differs from congenital undescended testes, and therefore, the risk of future malignant tumors may also differ 6 . So far, there has been only one isolated report of intratubular germ cell neoplasia (ITGCN) in residual testicular ducts in a 9-year-old child, but it lacked immunohistochemical support 25 . The controversy over whether to excise atrophic nodules arises from different reported rates of GC occurrence 3 , 4 , 5 , 10 , 16 and the subsequent risk of malignancy.A large-scale retrospective study conducted until now indicated an overall incidence rate of 3.1% for GC and 6.6% for SNT 16 . However, a recent systematic review revealed that the overall incidence rate of GC is 5.3%, and SNT is 10.7% 6 . In our study, considering the potential medical disputes associated with excising testicular tissues and the unpredictable malignant potential of retaining atrophic testicular nodules, parents were allowed to observe the atrophy of the testicles during surgery and choose between excision and fixation. Based on this, we divided the patients into excision and fixation groups. There were no significant differences between the two groups in terms of patient age, affected side, CTH, testicular location, and preferred surgical incision. However, the fixation group had two cases of postoperative scrotal incision infections, which showed statistical significance. In the excision group, we found an SNT occurrence rate of 7.1% and a GC occurrence rate of 4.5%. Postoperative follow-up did not reveal abnormal development or torsion of the contralateral testicle. In the fixation group, no malignant conditions were detected by ultrasound, and there were no cases requiring a second excision surgery. At the same time, we observed that 336 cases (91.3%) of patients underwent excision surgery, a relatively high proportion that may reflect a preference for surgical interventions within parents. Despite our efforts to provide objective information regarding treatment options, we cannot rule out the potential influence of personal preferences within the medical team and concerns from parents about future risks on the decision-making process. Interestingly, in this study, we discovered a case of EACT. First discovered by Morgagni in 1740 26 , EACT can be found anywhere along the migration path from the urogenital ridge during embryonic development. While descriptions of EACT have been reported in the abdomen, broad ligament, testicles, spermatic cord, kidneys, and retroperitoneum 11 , it is rarely reported in atrophic testicular nodules. Although the number of reported cases is limited, EACT is generally accepted to have malignant potential 11 , 27 , thus recommending excision.

By reviewing the literature, the low occurrence rates of SNT and GC and insufficient evidence supporting the continuous existence of future malignant potential lean towards the argument that surgical excision is unnecessary 3 , 6 , 10 . However, this overlooks the clinical significance of surgical procedures. VTS is a type of NPT, often requiring surgical exploration to determine the presence of viable testes. Considering the risk of scrotal incision infections after retaining atrophic nodules and the unpredictable malignant potential, even if the likelihood of malignancy is extremely low, parents find it difficult to accept. Therefore, we recommend excision.

Despite providing valuable data, this study has some limitations. Firstly, it has the limitations inherent in retrospective research, such as information completeness and selection bias. Secondly, the identification of SNT and GC in this study relied on H&E staining and lacked immunohistochemical results. Additionally, the follow-up period in this study was relatively short, requiring long-term follow-up of the malignant potential after retaining atrophic testicular nodules. Therefore, future prospective randomized controlled studies with long-term follow-ups will be more valuable.

In conclusion, in this study, SNT was found in 24 cases (7.1%) of excised atrophic remnants, GC in 15 cases (4.5%), and EACT in 1 case (0.3%). Although there is not sufficient robust evidence to prove the sustained malignant potential of GC and SNT over time, considering that VTS is a type of NPT requiring surgical exploration, and taking into account the risk of incision infection and the unpredictable malignant potential after retaining atrophic testicular remnants, which, even if low, is difficult for parents to accept, we recommend excision.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Vanishing testes syndrome

Contralateral testicular hypertrophy

Seminiferous tubules

Ectopic adrenal cortical tissue

Non-palpable testes

Hematoxylin and eosin

Standard deviation

Intratubular germ cell neoplasia

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C.-K.M designed the study and collect the data. Y.-F. analyzed the pathological data. Y.-S.C conducted statistical analyses. All the authors were involved in writing and reveiwing the manuscript as well as preparing the figures.

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Mao, CK., Yuan-Fang & Cao, YS. Management of pediatric vanishing testes syndrome based on pathological diagnosis: a single-center retrospective study. Sci Rep 14 , 9437 (2024). https://doi.org/10.1038/s41598-024-59583-6

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  1. Enterprise Risk Assessments

  2. REPORT: Risk Management 2021

  3. Intro to Management Video Case Study Report

  4. MGX1010

  5. Case study report (spot report, progress report and final report)

  6. CASE STUDY REPORT

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  1. Enterprise Risk Management Examples l Smartsheet

    The following examples of enterprise risk management can be considered success stories. ERM Case Study: Statoil. A major global oil producer, Statoil of Norway stands out for the way it practices ERM by looking at both downside risk and upside potential.

  2. Risk Management Articles, Research, & Case Studies

    New research on risk management from Harvard Business School faculty on issues including the role, organization, and limitations of risk identification and risk management, banks' risk exposures, and dealing with supply chain risk. ... In the new case study "Honeywell and the Great Recession," Sandra Sucher and Susan Winterberg explore ...

  3. Case Study in Enterprise Risk Management: Happy Tails, Inc

    management. In this thesis, I analyze a case study written by Robert Hoyt and Lily Waldron in 2020. titled "Happy Tails, Inc.". This case study describes the operations, organizational structure, history, and financial data of Happy Tails, a pet boutique focusing on natural dog food options.

  4. PDF Case Studies in Cyber Supply Chain Risk Management

    This Summary of Findings and Recommendations summarizes the Case Studies in Cyber Supply Chain Risk Management series' major findings and recommendations based on expert interviews. The Case Studies in Cyber Supply Chain Risk Management series engaged information security, supply chain, and risk leaders across a diverse set of organizations.

  5. Triangulating Risk Profile and Risk Assessment: A Case Study of ...

    Establishing an enterprise risk management (ERM) system is widely viewed as providing firms with the tools and processes needed to build resilience and expertise, enabling them to manage the consequences of crises that have led to the collapse of major firms across different industries globally. Intended for use in advanced accounting, auditing, and finance courses, this case study (of a true ...

  6. Enterprise Risk Management at Hydro One (A)

    The case challenges students to define the problems and risks that the company faces, given its strategic objectives, its evolving risk profile, and the changing environment. The case also offers a discussion ground for defining the role of the chief risk officer and the relationship between risk management, strategic planning and capital ...

  7. PDF Case Studies in Cyber Supply Chain Risk Management: Mayo Clinic

    These case studies build on the Best Practices in Cyber Supply Chain Risk Management case studies originally published in 2015 with the goals of covering new organizations in new industries and bringing to light any changes in cyber supply chain risk management practices. For information on NIST's Cyber Supply Chain Risk Management project, see.

  8. Risk Management Case Studies

    How do different organisations use Predict! to manage their risks and opportunities? Read our risk management case studies to learn from their experiences and insights. Find out how Predict! helps them to achieve their strategic objectives, deliver projects on time and budget, and improve their risk culture.

  9. Risk Management in Organizations: An Integrated Case Study Approach

    As noted in Section 2.8.1, risk should incorporate both opportunities (upside risks) and threats (downside risks). Therefore the management should be concerned with providing the necessary tools ...

  10. Risk Management in IT Projects

    Conclusions: It is important that the entire risk management process is standardizsed and . managed in an active manner . In the case study below , risk management was one of the success . factors ...

  11. PDF Quality Risk Management Principles and Industry Case Studies

    Case study utilizes recognized quality risk management tools. Case study is appropriately simple and succinct to assure clear understanding. Case study provides areas for decreased and increased response actions. 7. Case study avoids excessive redundancy in subject and tools as compared to other planned models. 8.

  12. Case study on risk management practice in large offshore‐outsourced

    The project selected for the case study consisted of multiple geographical locations. We mapped the risks and risk resolution techniques observed in the project, to the integrative framework for managing risks in GDSP as proposed by Persson et al. . The risk item, risk description and case study findings are shown in Tables 2-5. If ...

  13. PDF Risk Management Practices in a Construction Project a case study

    Department of Civil and Environmental Engineering Division of Construction Management. Chalmers University of Technology SE-412 96 Göteborg Sweden Telephone: + 46 (0)31-772 1000. Sweden 2011. Risk Management Practices in a Construction Project - a case study. Master of Science Thesis in the Master's Programme.

  14. PDF Information Security Risks Assessment: A Case Study

    This project carries out a detailed risk assessment for a case study organisation. It includes a comprehensive literature review analysing several professional views on pressing issues in Information security. In the risk register, five prominent assets were identified in respect to their owners.

  15. Risk Management in Construction Industry

    The Study investigated to acquire an overall idea about risk and its consequences in construction field and the process required for its management. The effect of risk on assessment of a project ...

  16. PDF Risk Management—the Revealing Hand

    global financial crisis. The concern is that top-down risk management will inhibit innovation and entrepreneurial activities. We disagree and argue that risk management should function as a Revealing Hand to identify, assess, and mitigat risks in a cost- e efficient manner. Done well, the Revealing Hand of risk management adds value to firms

  17. Risk management

    Ron Ashkenas. One corporate drama playing out in the news is the fate of Saab — a now-orphan division of General Motors that appears will narrowly escape extinction by last-minute buyer Spyker ...

  18. Case Study Gives Students Corporate Risk Management Experience

    Ryan Thielen (MBA '19) says going through the case study process is valuable because it allows students to "simulate real-world experience in a classroom setting.". "The HypoCom case offers a unique experience where students are able to function as consultants to evaluate a risk management problem and provide a strategic recommendation ...

  19. PDF Interest Rate Risk Management Case Study

    Interest Rate Risk Management Case Study Report No. EVAL-16-004 March 2016 Why We Did The Audit The FDIC has been concerned that certain institutions are not sufficiently prepared or positioned for sustained increases in, or volatility of, interest rates because rates have been exceptionally low for a prolonged period.

  20. PDF Case Study: A Practical Approach to Managing Risks for Small Businesses

    • Leverage existing risk management processes in various organizational departments (e.g., Internal Audit, Compliance / Legal). • Clearly communicate the benefits of a successful risk management program. • Build relationships along the way. Also, at this time it was decided that the term "enterprise risk management" would be referred ...

  21. Risk Management A Case Study

    Report Document. Students also viewed. Unit 2 Identifying and Analyzing Risks; Management's Role in Project Risk Management; ... Risk Management: A Case Study Introduction. You created your risk management plan and identified the risks to the project, determined the ones to which you need to respond, and crafted your action plans. ...

  22. Organizational risk management practices in time of crisis: an

    The purpose of this investigative case study research was to scrutinize the approaches of organizational risk management strategies applied by the Ethiopian Airlines throughout the global COVID-19 pandemic. It aimed at assessing and documenting risk management methodologies, best practices and lessons learned by the Airlines to survive the damaging impact the health crisis.

  23. Interrater reliability of the violence risk assessment checklist for

    Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12-18 (V-RISK-Y) is a 12-item violence risk screening ...

  24. USACE Chief of Engineers Signs Ponte Vedra Beach Coastal Storm Risk

    From USACE Jacksonville: Original story available here.. Lt. Gen. Scott A. Spellmon, 55th Chief of Engineers and Commanding General of the U.S. Army Corps of Engineers, signed the Chief's Report April 18, 2024, for the Ponte Vedra Beach Coastal Storm Risk Management Study Report in a ceremony at USACE Headquarters in Washington, D.C.

  25. (PDF) AGRICULTURE RISK MANAGEMENT: A CASE STUDY ON ROCK ...

    Abstract. The objectives of this study are to identify risks faced by farmers in agriculture project and investigate their risk management practices. The subject of investigation was a rock melon ...

  26. Management of pediatric vanishing testes syndrome based on ...

    The controversy over whether to excise atrophic nodules arises from different reported rates of GC occurrence 3,4,5,10,16 and the subsequent risk of malignancy.A large-scale retrospective study ...

  27. Dubai's Extraordinary Flooding: Here's What to Know

    One recent study of Sharjah, the capital of the third-largest emirate in the U.A.E., found that the city's rapid growth over the past half century had made it vulnerable to flooding at far lower ...

  28. What caused Dubai floods? Experts cite climate change, not cloud

    A storm hit the United Arab Emirates and Oman this week bringing record rainfall that flooded highways, inundated houses, grid-locked traffic and trapped people in their homes.