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CAI Webinar: Responding to Large Scale Adverse Events

Webinar presented by Dr. Tom Gallagher on Thursday, June 6, 2019

Large-scale adverse events, situations in which a breakdown in care has affected multiple (sometimes thousands) of patients, pose significant challenges for institutions related to responding in ways that inform potentially affected patients without unduly alarming them and managing the follow-up. This webinar will highlight lessons learned from the field around responding effectively to adverse events, as well as key unanswered questions.

Learning objectives:

  1. Describe the diversity of large-scale adverse events, and how responding to these events differs from managing adverse events that affect individual patients
  2. List the key elements of an effective response to a large-scale adverse events and the tools that are currently available to assist with this process
  3. Critique an actual large-scale adverse event patient notification letter and press release, and articulate opportunities for improvement in these documents.

The Journal of Patient Safety and Risk Management published study of an “open” hospital system shows that a Collaboration Communication-and-Resolution Program (CRP) cut lawsuits by two-thirds and reduced legal expenses and the time needed to resolve claims. Due to this program’s success, physicians are encouraged to integrate CRPs into their health practices to increase overall patient health quality and safety.


Physicians are urged to communicate more openly following medical errors, but little is known about pathologists’ attitudes about reporting errors to their institution and disclosing them to patients.The researchers of this article undertook a survey to characterize pathologists’ and laboratory medical directors’ attitudes and experience regarding the communication of errors with hospitals, treating physicians, and affected patients.

The importance of transparent and timely communication with patients following breakdowns in care is widely recognized. This article seeks to gain better understanding of breast cancer care providers’ attitudes regarding communicating with patients about diagnostic errors in order to inform interventions and to improve patient-provider discussions. Discussions focused on providers’ experiences with potential errors in breast cancer diagnosis, communication with patients following three hypothetical diagnostic vignettes, and suggestions for how and why diagnostic errors in breast cancer care should be communicated.

Journal Article
Published articles related to CRP
Disclosing Harmful Mammography Errors to Patients

Greater openness with patients about harmful errors is recommended. Many ethicists and professional organizations endorse disclosure of harmful errors to patients.The Joint Commission’s accreditation standards now require that patients be informed about unanticipated outcomes. In response, many hospitals are developing disclosure programs. Yet, recent studies suggest that disclosure of harmful medical errors to patients is the exception
rather than the rule. This article explores radiologists’ attitudes about disclosing errors to patients by using a survey with a vignette involving an error interpreting a patient’s mammogram, leading to a delayed cancer diagnosis.

Journal Article
Published articles related to CRP
Disclosing Harmful Pathology Errors to Patients

Medical errors are unfortunately common. In the United States, Institute of Medicine proposed a set of guidelines for mitigating and disclosing errors. In order to implement these recommendations in pathology, it will require a better understanding of how errors occur in pathology, the relationship between pathologists and treating clinicians in reducing error, and pathologists’ experiences with and attitudes toward disclosure of medical error.This article aims to understand pathologists’ attitudes toward disclosing pathology error to treating clinicians and patients.


Background Communication-and-resolution programmes (CRP) aim to increase transparency surrounding adverse events, improve patient safety and promote reconciliation by proactively meeting injured patients’ needs. Although early adopters of CRP models reported relatively smooth implementation, other organisations have struggled to achieve the same. However, two Massachusetts hospital systems implementing a CRP demonstrated high fidelity to protocol without raising liability costs.

Study question What factors may account for the Massachusetts hospitals’ ability to implement their CRP successfully?

Setting The CRP was collaboratively designed by two academic medical centres, four of their community hospitals and a multistakeholder coalition.

Data and methods Data were synthesised from (1) key informant interviews around the time of implementation and 2 years later with individuals important to the CRP’s success and (2) notes from 89 teleconferences between hospitals’ CRP implementation teams and study staff to discuss implementation progress. Interview transcripts and teleconference notes were analysed using standard methods of thematic content analysis. A total of 45 individuals participated in interviews (n=24 persons in 38 interviews), teleconferences (n=32) or both (n=11).

Results Participants identified facilitators of the hospitals’ success as: (1) the support of top institutional leaders, (2) heavy investments in educating physicians about the programme, (3) active cultivation of the relationship between hospital risk managers and representatives from the liability insurer, (4) the use of formal decision protocols, (5) effective oversight by full-time project managers, (6) collaborative group implementation, and (7) small institutional size.

Conclusion Although not necessarily causal, several distinctive factors appear to be associated with successful CRP implementation.

Many organizations have struggled to implement CRP models smoothly. The study looks at factors that accounts for the success of two Massachusetts hospital system in implementing a CRP with high conformity to protocol without raising liability costs. Identified factors include: support of top institutional leaders, heavy investments in educating physicians about the programme, active cultivation of the relationship between hospital risk managers.


Journal Article
Published articles related to CRP
Error Disclosure and Apology in Radiology: The Case for Further Dialogue

Momentum has grown around turning the principle of being transparent with patients about harmful errors into practice. Most radiologists remain profoundly uncomfortable with the prospect of talking with patients about errors. This article describes recent developments driving widespread disclosure and apology efforts in the United States and looks at encouraging radiologists to prepare to discuss errors directly with patients.

Two victims are involved in adverse incidents within health care. The first victim is the patient and family and the second is the health care provider. Researchers of this study focused on the effects of adverse events on healthcare professionals. They found that it is necessary to develop and implement support systems that can utilized by both patients, families, and healthcare providers when dealing with the effects of adverse incidents.


The Joint Commission Journal on Quality and Patient Safety (2012) created a toolkit to help health care organizations implement support programs for clinicians suffering from the emotional impact of errors and adverse events. Based on the best available evidence related to the second victim experience, the toolkit consists of 10 modules, each with a series of specific action steps, references, and exemplars.

Journal Article
Published articles related to CRP
Human error: models and management

The human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error management. Understanding these differences has important practical implications for coping with the ever-present risk of mishaps in clinical practice.



The response to adverse events can lack patient-centered-ness, perhaps because the involved institutions and other stakeholders misunderstand what patients and families go through after care breakdowns. A PFAC-designed simulation can help stakeholders understand patient and family experiences following adverse events and potentially improve their response to these events.



In an era of calls for greater transparency in health care, disclosure is often cited as a practice necessary to physician ethics and patient safety. The University of Michigan Health System (UMHS) experience demonstrates that disclosure with offer can be conducted—in a setting similar to many other centers in the United States—without exacerbating liability costs. UW Medicine hope that this study will encourage further disclosure efforts, as well as the detailed evaluation of their effects.


The University of Michigan Health System (UMHS) systematically adopted the “open disclosure with offer” model, a principle-based strategy that emphasizes honesty and disclosure, to effectively respond to adverse patient outcomes and healthcare malpractices. When the UMHS adoped this model, there was a gradual reduction in litigation fees and the number of malpractice and patient harm claims.


Alberta Health Services (AHS) adopted the Patient and Family Centered Care (PFCC) program to increase patient and family engagement in the healthcare settings. The PFCC encourages and trains patients, families, and healthcare workers to share their experiences and improve care. This program also offers methods to measure the effectiveness of this program.


Journal Article
Published articles related to CRP
Providers’ Perceptions of Communication Breakdowns in Cancer Care

Communication breakdowns in cancer care are unfortunately common and represent a failure in patient-centered care. While multiple studies have elicited patients’ perspectives on these breakdowns, little is known about cancer care providers’ attitudes regarding the causes and potential solutions. The purpose of this article is to examine providers’ (1) perceptions of the nature and causes of communication breakdowns with patients in cancer care and (2) suggestions for managing and preventing breakdowns.

Journal Article
Published articles related to CRP
Psychological Safety and Error Reporting Within Veterans hospitals

Previous studies suggest that psychologically safe workplaces foster a feeling of comfort among employees, allowing them to feel comfortable with taking risks, such as identifying mistakes in the workplace. In this study, researchers analyzed the levels of psychological safety in Veterans Health Administration (VHA) hospitals, and studied its relationship to employees’ comfort in disclosing medical mistakes. Researchers found that only a minority of workers were uncomfortable in admitting mistakes, and their discomfort was due to fear of retaliation.


Researchers concluded that an organizational culture characterized by anonymity, rewards and recognition for staff members making reports, grassroots involvement in the review and interpretation of data, and use of external sources of error data is critical for establishing a process truly capable of creating safety. This process for changing culture can be applied in any health care system desiring to improve the safety of the medication use process.


The authors of this study analyzed the importance of healthcare professionals being transparent in medical malpractices with their patients in the Texas healthcare system. The authors found that medical mishap litigation helped significantly reduce suing and other damages. The authors also emphasized the importance for healthcare systems to work with attorneys, policy makers, and patients to help develop methods to be more transparent about medical mishaps and enforce proactive mediation.



Journal Article
Published articles related to CRP
Saying “I’m Sorry”: Error Disclosure for Ophthalmologists.

This commentary spotlights elements of ophthalmology practice that can influence error disclosure, particularly the prevalence of patients receiving care from optometrists outside the hospital environment with no central reporting mechanism.


Expectations for how radiologists should communicate with patients are in rapid evolution. Of all the communication challenges radiologists may encounter, disclosing harmful radiologic errors to patients looms as perhaps the most difficult. Calls are increasing for radiologists to communicate directly and transparently with patients after errors. This article explores the direct radiologist-to-patient disclosure of harmful radiologic errors. It further explores the profession’s aspirations toward enhanced patient care, professionalism, and visibility.

In the BMJ Quality & Safety Study (2009), researchers studied why clinicians are often considered “second victims” in the wake of medical errors. The researchers delved into how healthcare providers recover from the guilt and stress involved medical errors, and discuss the elements related to recovery and delineate from the second victim phenomenon. These factors include moving forward, receiving emotional support, and reestablishing a sense of integrity. Researchers recommended that it is important to for healthcare institutions to implement support systems that not only offer emotional aid but also decrease the likelihood of future adverse events.




Researchers acknowledged how a majority of adverse medical events involve patient harm. Patients and family are known as first victims. Researchers also acknowledged how healthcare professionals are also considered victims after an adverse event, due to the emotional and psychological trauma experienced after it. In other words, healthcare professionals are also known as second victims. In this study, researchers analyzed the various coping strategies that clinicians use in the wake of adverse events. These strategies include attending programs that offer emotional aid second victims, as well as taking accountability for the situation and learning from it.


Medical errors not only negatively affect patients involved but also healthcare workers, to the point that they have been dubbed “second victim” due to the psychological and emotional stress caused from the event. In this study, researchers examined how healthcare workers recover from medical errors. Recovery methods include receiving emotional first aid, re-developing a sense of integrity, and learning to cope with the negative event.


Journal Article
Published articles related to CRP
The path to safe and reliable healthcare

This article discusses the importance of implementing a holistic approach to address both processes and culture in providing safe and exceptional care to patients. This article also includes a road map for healthcare providers, so they can efficiently assess the strengths and weakness of their current care system, so they can organized and intentional in their work, allowing them to improve overall patient care and safety in any clinical setting.


Journal Article
Published articles related to CRP
The Second Victim of Adverse Health Care Events, Nursing Clinics

This article discusses on how healthcare professionals are often considered “second victims” of adverse medical events, due to the psychological and emotional trauma they experience. To support second victims, it is important for health institutions to implement early warning systems that address harm risks associated with adverse incidents. In this article, researchers specifically focus on nurses and how respond to adverse medical events.


The objective of this study was to determine whether a communication-and-resolution program (CRP) to adverse patient events is correlated with changed in medical litigation actions and outcomes.  Researchers found that the implementation of a communication and optimal resolution (CANDOR) program was most successful. These programs consist of methods for effectively identifying an event, investigation, resolution, and care for healthcare providers. The CANDOR program was correlated with long-lasting fiscal and clinical improvements. It also helped increase incident report rates, as well as decrease the number of litigation and malpractice claims and fees.



The purpose of this study was to determine whether a communication and optimal resolution (CANDOR) program was effective in reducing the number of health liability processes and associated adverse outcomes. Researchers found that this program helped significantly increase the number of incident reports received, as well as decreased the litigation, settlement, and self-insurance fees associated with medical malpractices and adverse events.


Journal Article
Published articles related to CRP
Transparency and the “end result idea”

This article discusses the “end result idea,” a concept that describes that physicians should follow up with their patients after treatment to evaluate their results as well as to make these assessments public. The “end result idea” promotes the fact that physicians should be transparent with their patients as well as the public in addressing health outcomes. By being transparent, physicians and healthcare institutions can promote patient safety, healthcare professional learning, and overall healthcare quality.