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After Patient Ms. W received surgery on the wrong-site in her neck to relieve neck pain, she soon experienced adverse health effects, such as pain, distress, and lack of trust in healthcare providers. Ms. W’s experience illustrates the lack of communication between physicians and patients. The discrepancy is poor physician communication and refusal of apologizing for malpractice is due to fear of litigation. To improve patient-physician communication, health systems are encouraged to implement programs that encourage disclosure among healthcare professionals and trainees to improve overall healthcare quality.


The root causes of medical malpractice claims are deeper and closer to home than most in the medical community care to admit. The University of Michigan Health System’s experience suggests that a response by the medical community more directly aimed at what drives patients to call lawyers would effectively reduce claims, without compromising meritorious defenses. More importantly, honest assessments of medical care give rise to clinical improvements that reduce patient injuries. Using a true case example, this article compares the traditional approach to claims with what is being done at the University of Michigan. The case example illustrates how an honest, principle-driven approach to claims is better for all those involved—the patient, the healthcare providers, the institution, future patients, and even the lawyers.


Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different sources and institutions. Incident reports collected from IRS, patient complaints and retrospective chart review in an academic acute care hospital were classified using the ICPS. In conclusion, IRS do not capture all incidents in hospitals and should be combined with complementary information about diagnostic error and delayed treatment from patient complaints and retrospective chart review. Since incidents that are not recorded in IRS do not lead to remedial and preventive action in response to IRS reports, healthcare centres that have access to different incident detection methods should harness information from all sources to improve patient safety.

 


The nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue during a one-day conference. They discussed pertinent issues, patient and family experiences after serious harmful events, including profound isolation, psychological distress, damaging aspects of medical culture, health care aversion, and negative effects on communities. The group also created a strategy for overcoming research barriers and actionable “Do Now” approaches to improve the patient and family experience while research is ongoing.


Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
A Roadmap for Patients and Families in the Center of Healthcare

The Roadmap for Patient and Family Engagement in Healthcare Practice and Research was created as a call to action for anyone interested in advancing work related to patient and family engagement. It includes eight change strategies and five simple actions to increase patient and family involvement in the improvement and implementation of extraordinary healthcare.

 


This article discusses the negative connotations that surround the term “second victim,” which is used to describe healthcare providers following their involvement in a adverse medical incident. Authors of this article persuade people to stop using this term, since it discourages healthcare providers from taking responsibility for their actions, as well as undermines the patient’s feelings and situation.


This article discusses the prevalence of disruptive behavior in the healthcare setting, which is defined as any act that influences a group’s intended outcome. Disruptive behavior often takes the form of angry outbursts and passive aggressive actions, especially in extremely stressful environments, such as emergency rooms. This behavior is often detrimental to the culture of safety and quality healthcare, as well as increases the risk of lawsuits. To combat disruptive behavior, five principles are are offered as guides to promoting professionalism and professional accountability in support of quality team-oriented care, patient safety and, if necessary, legal defense if disruptive colleagues challenge disciplinary interventions. 


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
Agency for Healthcare Research and Quality (AHRQ)

The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of America’s health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions.


Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
Agency for Healthcare Research and Quality (AHRQ) Primer: Patient Safety Event Reporting

Incident reporting is the most common method used to promote patient safety in healthcare settings. This method requires those involved in the event go complete an incident form, which is a detailed summary of the occurrence. There are key components that make incident reporting systems effective and successful. To be successful, the incidence form should be submitted in a timely manner and be disseminated among an array of healthcare professionals.


Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
Agency for Healthcare Research and Quality (AHRQ): Advances in Patient Safety

Advances in Patient Safety: From Research to Implementation describes what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety over the last five years. This compendium is sponsored jointly by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD)-Health Affairs. The 140 articles in the 4-volume set cover a wide range of research paradigms, clinical settings, and patient populations. Where the research is complete, the findings are presented; where the research is still in process, the articles report on its progress. In addition to articles with a research and methodological focus, the compendium includes articles that address implementation issues or present useful tools and products that can be used to improve patient safety.


The Agency for Healthcare Research and Quality (AHQR) developed the CANDOR (Communication and Optimal Resolution) Event Checklist, which is a guide to be used by the CANDOR team after an adverse event occurred in the healthcare setting. The checklist includes effective ways of reporting, assessing, investigating, and analyzing the adverse event to decrease the likelihood of future incidents occurring, as well as improving the overall quality of patient care and safety.


The CANDOR Event Review Report Template is a guide used to analyze and investigate barriers that contributed to an adverse health event. Barriers include poor communication behaviors, unsafe physical environment, inadequate care, and equipment device failure. This template also includes a guide to assess who was responsible for the adverse event, and ways to develop solutions for it so it.


Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
Agency for Healthcare Research and Quality (AHRQ): CANDOR Toolkit

The Communication and Optimal Resolution (CANDOR) process is used  by health care institutions and practitioners to respond in a timely, thorough, and just way when unexpected events cause patient harm. The CANDOR toolkit contains eight different modules, which contain PowerPoint slides with facilitator notes, tools, resources, or videos. Examples of modules include “Care for the Caregiver” and “Organizational Learning and Stability.” These modules focus on effective ways to reduce patient harm and increase overall healthcare quality and safety through family and patient engagement, as well as specific ways to decrease the risk of future adverse outcomes.


The Guide to Patient and Family Engagement in Hospital Quality and Safety was developed by the for Healthcare Research and Quality (AHRQ) to encourage patient and family involvement in healthcare quality and safety. This guide includes four key methods as follows:

  • Encourage patients and family members to participate as advisers.
  • Promote better communication among patients, family members, and health care professionals from the point of admission.
  • Implement safe continuity of care by keeping the patient and family informed through nurse bedside change-of-shift reports.
  • Engage patients and families in discharge planning throughout the hospital stay.

Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
American Medical Association: State medical liability reform

Read how the AMA pursues medical liability laws on the state level to reshape the current medical liability system to better serve both physicians and patients.


Video
CRP related video, movie
Annie’s Story

“Annie’s Story” is an example of how healthcare organizations seeking high reliability embrace a just culture in all they do. This includes a system’s approach to analyzing near misses and harm events—looking to analyze events without the knee-jerk blame and shame approach of old. This video specifically focused on Nurse Andrea’s personal experience with an adverse health event with a patient who underwent a hypoglycemic emergency due to a misreading of a glucometer. The video then details the steps she and the hospital took to prevent future adverse health events, as well as other ways to increase overall patient safety and quality.


Learning Community
Resources associated with CAI Learning Community
Presentation/Webinar
Recorded webinars and presentations
Video
CRP related video, movie
APOLOGY AND DISCLOSURE GRAND ROUNDS — NWH

The Apology and Disclosure Grand Rounds NWH incorporates a video simulated error and a presentation about “When Things Go Wrong”. The presentation discusses disclosure coaching & peer support, the emotional impact of errors on clinicians, and principles for transparent & compassionate disclosure and apology.


Journal Article
Published articles related to CRP
Apology laws and malpractice liability: what have we learned?

39 states have apology laws, with over a third applying to healthcare or other contexts. After over a decade of experience with apology laws, the authors explore whether apology laws reduce malpractice liability risk and why, and whether there is a reason to have them.


Medical errors are associated with significant emotional, financial, physical and sociobehavioural impacts including reduced trust and willingness to seek healthcare. These impacts can last for years. The study sought to understand whether greater open communication is associated with reduced emotional impacts and decreased avoidance of doctors/facilities involved in the error.


Journal Article
Published articles related to CRP
Balancing “no blame” with accountability in patient safety

This article explains the challenge of balancing accountability and a “no blame” model in healthcare systems when promoting patient safety. Accountability is defined as taking responsibility for one’s actions. In this article, it is taking responsibility for malpractice that increases patient harm. the “no blame” model is defined as not accusing a single entity for any healthcare misconduct. It is important for healthcare systems to embody both taking responsibility for healthcare malpractices as well as the “no blame” model to effectively promote patient safety and quality and reduce adverse health events.


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
Betsy Lehman Center for Patient Safety- Patient Resources

Resources for patients and families in need of information and support after a medical error or adverse medical event.


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
Betsy Lehman Center for Patient Safety- Peer Support

Resources for clinicians and staff looking for data and information about the importance of support after adverse medical events, or for administrators that are interested in implementing a peer support program at their institution.


Timothy McDonald, MD, JD, discusses factors that can make already difficult conversations with patients and their loved ones after harm events even more challenging and complex and offers recommendations to mitigate these challenges.


Learning Community
Resources associated with CAI Learning Community
CAI Issue Brief 2: Mitigating the Toll of Medical Errors on Clinicians

Jo Shapiro, MD, FACS, talked about how peer support programs can both help alleviate some negative emotional impact of medical errors on the involved clinicians and in progression towards a culture of psychological safety in organizations.


Learning Community
Resources associated with CAI Learning Community
Presentation/Webinar
Recorded webinars and presentations
Video
CRP related video, movie
CAI Webinar: Challenging Conversations with Patients and Families

Challenging Conversations with Patients and Families presented by Dr. Tim McDonald

Communicating with patients and families following unexpected patient harm can be challenging even in optimal conditions; it is a learned skill. Taking into consideration factors such as socio-economic status, religion, cultural preferences, marital status, sexual orientation and gender identity is important to communicating effectively. This webinar covers methods successfully employed by healthcare institutions to recognize, plan for, and communicate effectively in complex situations and with special groups.

Learning Objectives

After completing this webinar, attendees will be able to…

1. Demonstrate recognition of situations that require advanced techniques for communicating unexpected patient outcomes;

2. Utilize communication enactments in conducting ongoing training in these complex situations within their organizations.


Learning Community
Resources associated with CAI Learning Community
Legislation/Regulation/Other legislative
Laws relating to CRP
Presentation/Webinar
Recorded webinars and presentations
CAI Webinar: Covid-19 and Medicolegal Liability

WEBINAR DATE: May 1, 2020

The COVID-19 pandemic is posing a host of potential medicolegal risks for healthcare providers, institutions, and liability insurers. How should one respond to the patient with behavioral challenges who refuses to comply with social distancing? How do COVID requirements affect consent and surrogate decision-making? What new legal issues are arising with rapid expanding telehealth programs or deploying providers to new care environments such as nursing homes? In what situations should healthcare providers or organizations be provided with immunity for potential adverse events associated with COVID-19 care?

PRESENTERS:

Moderator
Thomas H. Gallagher, University of Washington
Panelists
Marcia Rhodes, University of Washington
Leilani Schweitzer, Stanford Health
Michael Severyn, ProAssurance
Kyle Sweet, Sweet Law Firm

OBJECTIVES:

1. Identify current medicolegal issues associated with COVID-19
2. Consider how medicolegal issues associated with COVID-19 may evolve in the future
3. Discuss possible ways to address these issues

 


Learning Community
Resources associated with CAI Learning Community
Presentation/Webinar
Recorded webinars and presentations
Video
CRP related video, movie
CAI Webinar: CRPs: Why the insurance industry hasn’t embraced them . . . and why it should

CRPs: Why the insurance industry hasn’t embraced them . . . and why it should presented by Richard Boothman, JD

The driving ideas behind CRPs continue to draw interest and debate, now twenty years after Steve Kraman and Ginny Hamm published their Lexington, KY VA experience with “Extreme Honesty”.  After more than 17 years, the University of Michigan continues to draw attention transparent with their “Michigan Model”, the most successful and longest continual example of a principled, and proactive approach to patients injured in unexpected clinical outcomes.  After years of balking at abandoning “deny and defend” more health systems around the country and around the world are exploring the transition, but a skeptical insurance industry continues to hold back and sometimes, frustrate the desires of their insureds to move in this direction.  Why?  Is the industry’s skepticism well-founded and prudent?  Or is it missing a valuable opportunity?

Rick Boothman, the architect of the “Michigan Model” will initiate a long-deserved discussion into this topic.  His experience suggests that there are multiple insurance advantages in the CRP approach and the insurance industry should rethink old beliefs, practices and prejudices and embrace this model.

Outline

  1. Insurance 101 – a dummy’s guide to the construct
  2. True CRPs – the essential elements and how the model differs from “deny and defend”
  3. What holds the insurance industry back from jumping on board?
  4. What is the insurance industry missing and why should it matter?

Learning Objectives

  • That too many equate CRPs only with selective, early resolution of potential and asserted claims – what are the essential elements that distinguish a true CRP from established, traditional risk management practices?
  • What are the unique outcomes of a CRP and why do they matter?
  • Why a CRP better serves the interests of healthcare insureds?
  • What unique consequences of a CRP would benefit the insurance industry especially?

Learning Community
Resources associated with CAI Learning Community
Presentation/Webinar
Recorded webinars and presentations
Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
Video
CRP related video, movie
CAI Webinar: Large Scale Implementation of Communication and Resolution Programs

Large Scale Implementation of Communication and Resolution Programs

Presented by: Heather Gocke, M.S., RNC-OB, CPHRM, C-EFM

Webinar Date: January 29, 2020

Ms. Gocke introduces a comprehensive program and a holistic approach in reducing harm in healthcare through large scale implementation of CRP. In her presentation, she highlights the importance of disclosure and engagement, and she shares real-life challenges and secrets to success.

Learning Objectives:

  1. Outline the method used to engage member sites in culture transformation
  2. Learn  how culture measurement, survey data debriefs, and cognitive interviewing techniques are used to inform this body of work
  3. Introduce the five domains and components of BETA HEART

Learning Community
Resources associated with CAI Learning Community
Presentation/Webinar
Recorded webinars and presentations
Video
CRP related video, movie
CAI Webinar: Mitigating the Toll of Medical Errors on Clinicians

Mitigating the Toll of Medical Errors on Clinicians by Jo Shapiro, MD, FACS

Webinar Date: October 31, 2019

As a clinician, being involved in adverse events can have devastating emotional consequences. How we react to these events – as individuals, colleagues and organizations – has a major effect on our organizational culture of psychological safety, provider wellbeing, disclosure and reporting, and patient safety.  Dr. Shapiro’s presentation will detail these effects and address the unique role that frontline physicians can play in supporting one another after adverse events. She will describe the peer support program developed at Brigham and Women’s Hospital and adopted by dozens of healthcare organizations. She will describe the building blocks of a creating and sustaining a peer support program, including providing the participants with the rationale to bring to leadership in advocating for peer support program resources.

Learning Objectives:

  1. Identify the emotional impact of adverse events on clinicians
  2. Recognize the impact this has on a culture of psychological safety, provider wellbeing, disclosure and reporting, and patient safety.
  3. Provide a rationale to leadership for developing a peer support program
  4. Delineate the foundational aspects of a peer support program

 


Learning Community
Resources associated with CAI Learning Community
Presentation/Webinar
Recorded webinars and presentations
Video
CRP related video, movie
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.