Tools and Resources[ Show all or clear results ]

Incident reporting systems 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.


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)

Agency for Healthcare Research and Quality

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

Overview of adverse event reporting including Background, Characteristics of Incident Reporting Systems, Limitations of Event Reporting, Using Event Reports to Improve Safety, Current Context


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 a process that health care institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm.

The CANDOR toolkit contains eight different modules, each containing PowerPoint slides with facilitator notes. Some modules also contain tools, resources, or videos.


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.


Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
Canadian Patient Safety Institute: Patient Safety Management Toolkit

From the Canadian Patient Safety Institute

Prevent Patient Safety Incidents and Minimize Harm When They Do Occur
When a patient’s safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. CPSI provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process.

Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.


Joint Commission Journal on Quality and Patient Safety, 2010

A unique rapid response system was designed to provide social, psychological, emotional, and professional support for health care providers who are “second victims”–traumatized as a result of their involvement in an unanticipated adverse event, medical error, or patient-related injury.


Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
CDC large-scale adverse event (LSAE) patient notification toolkit

A Guide to Assist Health Departments and Healthcare Facilities with Conducting a Patient Notification Following Identification of an Infection Control Lapse or Disease Transmission.

Unsafe injection practices and other lapses in basic infection control put patients at risk of infection. These incidents have occurred in a wide variety of healthcare settings (e.g., hospitals, outpatient clinics, assisted living facilities). When these practices or the resulting infections are discovered, a patient notification process typically ensues. This toolkit is intended to assist state and local health departments or healthcare facilities in conducting a patient notification.


Journal Article
Published articles related to CRP
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.
Clinician Support: Five Years of Lessons Learned

Article: Clinician Support: Five Years of Lessons Learned
By Laura E. Hirschinger, RN, MSN; Susan D. Scott, RN, PhD; and Kristin Hahn-Cover, MD

University of Missouri Health Care (MUHC) deployed an evidence-based emotional support structure for second victims based on research with recovering second victims known as the forYOU Team. It was designed to increase awareness of the second victim phenomenon, “normalize” the psychological and physical impacts, provide real-time surveillance for possible second victims within clinical settings, and render immediate peer-to-peer emotional support when a potential second victim is identified. This article describes the forYOU Team experience.


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.
Communication and Resolution Program Certification (Washington Patient Safety Coalition)

This is the website for the Washington Patient Safety Coalition’s (WPSC) Communication and Resolution Program in the state of Washington.

Of significance is the WPSC’s CRP Certification program. When healthcare providers and organizations have utilized a CRP following an adverse event, they can apply for “CRP Certification.” A neutral group of patient safety experts and patient advocates has been convened to review responses to adverse events and certify whether the patient’s needs have been met, any individual or system-level inadequacies have been addressed, and learning has occurred. The certification process provides valuable feedback to healthcare organizations and demonstrates that they achieved all the essentials of a CRP.

The Washington Patient Safety Coalition is a program of the Foundation for Health Care Quality (The Foundation). The Foundation is a nonprofit organization dedicated to providing a trusted, independent, third party resource to all participants in the health care community – including patients, providers, payers, employers, government agencies, and public health professionals.


A CRP brochure from the Collaborative for Accountability and Improvement describing: CRP Core Commitments, Key Steps in the CRP Process and Launching a CRP. A very good paper to begin an understanding of CRP.

The Collaborative for Accountability and Improvement brings together leading experts to support the growth and spread of Communication and Resolution Programs (CRPs), advocate on behalf of these programs with a shared voice, and exchange ideas. CRPs drive quality improvement, enhance patient safety, and facilitate patient-centered accountability.

The Collaborative, which is currently based at the University of Washington, is poised to bring these programs to scale in the US and beyond

 


Videos from The Risk Authority, Stanford in partnership with Aon, Lockton UK, MedPro Group and SorryWorks!

Communication and Resolution Programs (CRPs) promise to reduce liability costs, promote a culture of safety and provide a vehicle for disclosure and healing between providers and patients after a medical error. Over the past decade, several CRPs have been pioneered and studied at leading medical centers.

In this live webcast event, we brought together three leading voices in the field – a health law scholar, a physician and a patient, to discuss:

Topics will include:

Have CRPs delievered on their promise?
What do the data show?
What best practices have emerged?
What challenges need to be overcome?
What resources are available to institutions interested in exploring or strengthening CRPs?


In communication-and-resolution programs (CRPs), health systems and liability insurers encourage the disclosure of unanticipated care outcomes to affected patients and proactively seek resolutions, including offering an apology, an explanation, and, where appropriate, reimbursement or compensation. Anecdotal reports from the University of Michigan Health System and other early adopters of CRPs suggest that these programs can substantially reduce liability costs and improve patient safety. But little is known about how these early programs achieved success. We studied six CRPs to identify the major challenges in and lessons learned from implementing these initiatives. The CRP participants we interviewed identified several factors that contributed to their programs’ success, including the presence of a strong institutional champion, investing in building and marketing the program to skeptical clinicians, and making it clear that the results of such transformative change will take time. Many of the early CRP adopters we interviewed expressed support for broader experimentation with these programs even in settings that differ from their own, such as systems that do not own and control their liability insurer, and in states without strong tort reforms.

January 2014


Case Study
Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
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.
Comprehensive Unit-based Safety Program (CUSP)

The Comprehensive Unit-based Safety Program (CUSP) was created by Johns Hopkins patient safety researchers and brought to the public domain through the Agency for Healthcare Research and Quality (AHRQ). CUSP aims to improve patient safety culture while providing frontline caregivers with the tools and support that they need to tackle the hazards that threaten their patients.

The AHRQ toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. It builds the capacity to address safety issues by combining clinical best practices and the science of safety.

It is noteworthy that between 2009 and 2011 the “On the CUSP: Stop BSI [Blood Stream Infections]” succeeded in reducing CLABSIs [Central Line Blood Stream Infections] nationwide. States reduced their adult ICU rate from a baseline of 1.915 infections per 1,000 line days to a rate of 1.133 infections, or a relative reduction of 41 percent. (https://www.ahrq.gov/professionals/quality-patient-safety/cusp/clabsi-final/clabsifinal3.html)


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
COPIC Insurance: 3Rs Program – Recognize, Respond, and Resolve

COPIC Insurance Company’s Communication and Resolution program.

From the website:

“When a patient experiences an unexpected medical outcome, they expect honest, open communication and sincere concern from his or her provider about the situation (including an apology when appropriate). In addition, a discussion of the steps that will be taken to prevent reoccurrence of the incident is appropriate in certain situations.

The goals of the 3Rs® Program—to maintain the physician-patient relationship, facilitate open and honest communication and disclosure, and reimburse the patient for related out-of-pocket medical expenses—have remained steadfast throughout the past eleven years.”

COPIC provides medical professional liability insurance.

 


Journal Article
Published articles related to CRP
Effectiveness and efficiency of root cause analysis in medicine

Root cause analysis has been widely adopted as a central method to learn from mistakes and mitigate hazards. Although there have been some benefits, including increased awareness of faulty processes and fixes to specific problems, there is an undercurrent of sentiment that this approach has limited effectiveness.

 


Adverse events within health care settings can lead to two victims. The first victim is the patient and family and the second victim is the involved health care professional. The latter is the focus of this review. The objectives are to determine definitions of this concept, research the prevalence and the impact of the adverse event on the second victim, and the used coping strategies. Therefore a literature research was performed by using a three-step search procedure. A total of 32 research articles and 9 nonresearch articles were identified. The second victim phenomenon was first described by Wu in 2000. In 2009, Scott et al. introduced a detailed definition of second victims. The prevalence of second victims after an adverse event varied from 10.4% up to 43.3%. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. After the adverse event, defensive as well as constructive changes have been reported in practice. The second victim phenomenon has a significant impact on clinicians, colleagues, and subsequent patients. Because of this broad impact it is important to offer support for second victims. When an adverse event occurs, it is critical that support networks are in place to protect both the patient and involved health care providers.

September 2012


Article from Health Affairs, 2014

Communication-and-resolution programs (CRPs) in health care organizations seek to identify medical injuries promptly; ensure that they are disclosed to patients compassionately; pursue timely resolution through patient engagement, explanation, and, where appropriate, apology and compensation; and use lessons learned to improve patient safety. CRPs have existed for years, but they are being tested in new settings and primed for broad implementation through grants from the Agency for Healthcare Research and Quality. These projects do not require changing laws. However, grantees’ experiences suggest that the path to successful dissemination of CRPs would be smoother if the legal environment supported them. State and federal policy makers should try to allay potential defendants’ fears of litigation (for example, by protecting apologies from use in court), facilitate patient participation (for example, by ensuring access to legal representation), and address the reputational and economic concerns of health care providers (for example, by clarifying practices governing National Practitioner Data Bank reporting and payers’ financial recourse following medical error).


Joint Commission Journal on Quality and Patient Safety, 2012

A toolkit was developed 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.


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.
Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF)

The Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) began working together as one organization in May 2017. The newly formed entity is committed to using its combined knowledge and resources to focus and energize the patient safety agenda in order to build systems of safety across the continuum of care.

The IHI and NPSF are considered the premier industry organizations for patient safety.


Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
Just Culture algorithm tool

Need algorithm


Book by Sidney Dekker.

A just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimize the negative impact, and maximize learning? This third edition of Sidney Dekker’s extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules.

About the author: Sidney Dekker (PhD Ohio State University, USA, 1996) is currently professor at Griffith University in Brisbane, Australia, where he runs the Safety Science Innovation Lab.


Journal Article
Published articles related to CRP
Leading Change: Why Transformation Efforts Fail, John P. Kotter

John P. Kotter is renowned for his work on leading organizational change. In 1995, when this article was first published, he had just completed a ten-year study of more than 100 companies that attempted such a transformation. Here he shares the results of his observations, outlining the eight largest errors that can doom these efforts and explaining the general lessons that encourage success.


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
MACRMI

MACRMI is a Massachusetts alliance of patient advocacy groups, teaching hospitals and their insurers, and statewide provider organizations committed to transparent communication, sincere apologies and fair compensation in cases of avoidable medical harm. We call this approach Communication, Apology, and Resolution (CARe) and we believe it is the right thing to do. It supports learning and improvement and leads to greater patient safety.


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.
Medically Induced Trauma Support Services (MITSS)

Medically Induced Trauma Support Services (MITSS) produces programs that provide education to the healthcare community on medically induced trauma, the broad scope of its impact, and the crucial need for support services. MITSS provides training and support to patients and family members.


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
Process for Early Assessment, Resolution and Learning (PEARL), Risk Authority Stanford

PEARL – the Process for Early Assessment, Resolution and Learning. A Communication and Resolution program provided by the Risk Authority Stanford.

From the website: “a way to manage unexpected outcomes with honesty, dignity and respect. There is a way to provide the answers that patients and caregivers really need. And there is a way to do this while reducing risk and claim costs.”

About the Risk Authority Stanford: created from the hospital risk management department serving the Stanford University School of Medicine, Stanford Health Care and Stanford Children’s Health. It provides services and solutions to these institutions and health systems, health plans, medical groups and other healthcare and non-healthcare organizations outside of the Stanford family.


Book/Report
Reference to book or report
RCA²

Report issued by the National Patient Safety Foundation.

Root Cause Analyses and Actions, or RCA2(RCA “squared”)

Root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives. With a grant from The Doctors Company Foundation, the National Patient Safety Foundation convened a panel of subject matter experts and stakeholders to examine best practices around RCAs and develop guidelines to help health professionals standardize the process and improve the way they investigate medical errors, adverse events, and near misses.


Author, Sidney Dekker

Thoroughly exploring an emerging topic with great relevance to safety culture, Second Victim: Error, Guilt, Trauma, and Resilience examines the lived experience of second victims. It goes through what we know about trauma, guilt, forgiveness, and injustice and how these might be felt by the second victim. Sidney Dekker discusses how to conduct investigations of incidents that do not alienate second victims or make them feel even worse. It explores the importance support and resilience and where the responsibilities for creating it may lie.


Patient and family engagement information sheet/methods from Alberta Health Services.

From the website:

“There are many ways to gain the valuable insights of patients and families! From the point of care to the planning table, seeing your work through the eyes of patients and families has been shown in the research to improve patient safety, improve health outcomes and reduce costs. Start small or consider more extensive action depending on your needs!”


Journal Article
Published articles related to CRP
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.
Sharing the load: Rescuing the healer after trauma

December 2008’s RN Magazine’s cover story shares the University of Missouri Healthcare System’s journey toward better understanding and providing support for its nurses on the sharp end of a medical error or unexpected patient decline.

RN. 2008 Dec;71(12):38-40, 42-3.