Tools and Resources[ Show all or clear results ]

Published articles related to CRP

Journal Article
Published articles related to CRP
Personal accountability in healthcare: searching for the right balance

Authors of this article emphasize how the “no blame” approach should be balanced with accountability when promoting patient safety in healthcare settings. However, this balance should be distributed among healthcare professionals, patients, and family members when effectively improving and promoting patient care and safety.

 

 


The purpose of this study was to identify certain communication behaviors linked with poor healthcare practice history in medical professionals. Researchers identified specific communication acts correlated with fewer malpractice allegations for physicians. Effective communication behaviors included utilizing humor and encouraging patients to express their opinions. Physicians can use these results to not only increase effective communication with their patients but to also decrease the risk of misbehavior and carelessness in the healthcare setting.

 


The authors of this article analyzed the importance of developing a support system for physicians so they can effectively cope with stress in the workplace, especially following an adverse medical event. Researchers found that peer support groups are one of the most effective support systems for physicians.

 


Improving how health care providers respond to medical injury requires an understanding of patients’ experiences. Although many injured patients strongly desire to be heard, research rarely involves them. Institutional review boards worry about harming participants by asking them to revisit traumatic events, and hospital staff worry about provoking lawsuits. Institutions’ reluctance to approve this type of research has slowed progress toward responses to injuries that are better able to meet patients’ needs. In 2015-2016, we were able to surmount these challenges and interview 92 injured patients and families in the USA and New Zealand. This article explores whether the ethical and medico-legal concerns are, in fact, well-founded. Consistent with research about trauma-research-related distress, our participants’ accounts indicate that the pervasive fears about retraumatization are unfounded. Our experience also suggests that because being heard is an important (but often unmet) need for injured patients, talking provides psychological benefits and may decrease rather than increase the impetus to sue. Our article makes recommendations to institutional review boards and researchers. The benefits to responsibly conducted research with injured patients outweigh the risks to participants and institutions.


Health care providers working on the front lines of the COVID-19 pandemic are threatened not only by exposure to the virus but also by pervasive and detrimental  effects on their mental health. Immediate actions need to be taken for a national strategy to safeguard the health and well-being of our clinicians. The article outlines 5 high-priority actions to protect the well-being of clinicians during and after COVID-19 crisis.

Written by: Victor J. Dzau, M.D., Darrell Kirch, M.D., and Thomas Nasca, M.D.


In this study, conference and process leaders were divided into three groups Morbidity and Mortality Conferences (MMCs), Educational Conferences, and Quality Assurance (QA) Meetings) to review adverse incidents and near misses, as well as to find ways to prevent them in the future as well as to promote patient safety. Researchers found that it is important to incorporate various approaches and clinical practices to effectively promote patient safety in the healthcare setting.

 


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.

 


Journal Article
Published articles related to CRP
RCA2: Improving root cause analyses and actions to prevent harm

The National Patient Safety Foundation (NPSF) published this report on root cause analyses and actions (“RCA2”), which are programs aimed to reduce the risk of adverse medical events and instead increase effective measures to reduce them in the future. This report illustrates strategies that healthcare organizations can utilize when implementing RCA2 programs in the workplace. This report also details specific strategies that help healthcare organizations identify the faults and hazards in their systems that increase the risk of adverse medical outcomes, as well as how to take active and positive steps to prevent them from happening in the future.

 

 


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 article analyzed how medical mistakes and injuries are correlated with high healthcare costs and poor patient quality. To lower these rates, the authors emphasized the importance of implementing an incident reporting system in healthcare settings. The implementation of these systems involve changing the culture of the workplace, so it promotes learning, flexibility, and blamelessness.

 


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
Respectful Management of Serious Clinical Adverse Events

A serious clinical adverse event is a crisis for everyone involved. Governing bodies and executive leadership carry the burden of these events forever, but carrying the burden isn’t enough. They also have a responsibility to ensure that everything possible is done to understand what happened and why it happened, and to prevent it from ever happening again. These crises have the power to be used to transform the organization to a dramatically better one. The individuals and organizations referenced in Acknowledgements, Appendix D, and the references in this white paper help to show us the way. This is the values-based “true north” of respectful management of serious clinical adverse events—the response that leaders would want for themselves and those they love. Health care leaders owe their patients, family members, staff, and community nothing less.

 


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.

 


Data from case studies support the fact that apologies from physicians to patients promote reconciliation and forgiveness. To promote a culture that supports apologizing and disclosure, 39 states, including Washington, D.C., are enacting apology policies to decrease the litigation problems surrounding medical malpractice. This article is delves into the implications surrounding the enactment of these laws. The article is divided into four parts. The first part of the article explains why states are passing apology laws and how they can help reduce lawsuits associated with medical malpractice. The second part presents data that supports the effectiveness of apology laws. The third part illustrates how apology laws affect various legal outcomes, especially the probability that medical providers will be presented with litigation fees. The fourth part of the article delves into the legal significance of their results. It is important to note that apology laws do not replace communication-and-resolution programs (CRPs), nor do they mitigate the existing data that these programs are effective in lowering the incidence rates of medical error claims.


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.

 


The Charter on Medical Professionalism, endorsed by the US Accreditation Council for Graduate Medical Education, requires physicians to engage in honest communication with their patients, especially regarding risks and benefits regarding medical procedures. However, researchers found that not all physicians abided by these rules which raises the concern that physicians may not fully disclose pertinent information with their patients, so they do not receive complete information. Honest communication between patients and their physicians is associated with patient comfort and willingness to move forward in medical procedures.

 


Journal Article
Published articles related to CRP
The Disclosure Dilemma — Large-Scale Adverse Events

Large-scale adverse events are individual events or a series of related events that injured or increased the risk that many patients would be injured because of health care management. There are ethical reasons why institutions may hesitate to disclose large-scale adverse events to patients. Practical, legal, and financial considerations, such as the difficulty in predicting the likelihood of harm and identifying the injured patients, may also lead well-meaning institutions to consider not disclosing large-scale adverse events. This article discusses two ethical frameworks often used in determining whether to disclose large-scale adverse events: utilitarian and duty-based. It also describes three examples of large-scale adverse events and discuss their distinguishing features.


Healthcare professionals are reluctant to apologize for medical errors, because they fear it could be used against them in lawsuits. In response to this issue, some states are developing policies that legally protect physicians, so they feel more comfortable apologizing to patients involved in medical errors. Even though these policies seem beneficial in theory, researchers found that these laws could discourage apologies and honest communication between patients and physicians following adverse medical events. Thus, researchers emphasize the importance for states to develop policies with modified legal protections and implications to not only promote disclosure between patients and physicians following adverse medical incidents, but also do not weaken the legal influence on lawsuits involving malpractice.


Journal Article
Published articles related to CRP
The Handbook of Communication and Social Interaction Skills

The Handbook of Communication and Social Interaction Skills is a holistic guide that draws form theories and surveys to improve communication and social interaction skills in various environments and settings. This handbook is divided into five sections: theoretical and methodological concepts (gaining and assessing skills); basic social interaction skills; persuading, informing, and supporting skills; various relationship skills (marriages, friendships, and romances); and skills necessary for public leadership and management (teaching and supervising).


Journal Article
Published articles related to CRP
The hard side of change management.

Authors of this article discuss how hard factors act as obstacles in change management. Hard factors have three characteristics: 1) Corporations can measure them in implicit and explicit ways, 2) corporations can communicate these factors both within in and outside of organizations, and 3) corporations can rapidly influence the previous elements. Authors emphasize that it is necessary for businesses to prioritize the hard factors before they can move forward and improve.


Journal Article
Published articles related to CRP
The Impact of Adverse Events on Clinicians: What’s in a Name?

The authors of this article discuss how physicians are dubbed “second victims,’ due to the negative emotional and psychological challenges they experience as a result of patient adverse incidents. The authors also illustrate how the term “second victim” can be a harmful term, since it implies passivity and mitigates the experiences of patients and families also affected by medical errors. It is argued that this term points to the necessity of healthcare institutions to implement support programs to help physicians heal and cope following the negative effects of adverse health outcomes.


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 Science of Human Factors: Separating Fact from Fiction

The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities.

Read more here.


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.

 


Journal Article
Published articles related to CRP
The Sorry Works! Coalition making the case for full disclosure.

This thesis paper delves into the importance of classifying healthcare conflicts into relationship-based groups  to appropriately address the dynamics, goals, and interventions associated with the conflict. These dynamics include ways of improving communication and rapports, as well as efficiently saving money.

 


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.

 


Patient and family emotional harm after medical errors may be profound. At an Agency for Healthcare Research and Quality (AHRQ) conference to establish a research agenda on this topic, the authors used visual images as a gateway to personal reflections among diverse stakeholders. Themes identified included chaos and turmoil, profound isolation, organizational denial, moral injury and betrayal, negative effects on families and communities, importance of relational skills, and healing effects of human connection. The exercise invited storytelling, enabled psychological safety, and fostered further collaborative discussion. The authors discuss implications for quality/safety, educational innovation, and qualitative research.