The Patient Notification Toolkit was developed to address injection and contagion control malpractice, which occurs in various healthcare settings, such hospitals, and assisted living facilities. These incidents compromise the patients’ health by increasing their risk of infection. When healthcare malpractices or resulting infections are exposed, patients are notified through a detailed process carried out by state and local health departments or healthcare facilities.

Operating communication and resolution programs (CRPs) where multiple organizations must collaborate can be highly challenging. Success likely requires several preconditions, including preexisting trust among organizations, active leadership engagement, physicians’ commitment to participate, mechanisms for quickly transmitting information to insurers, tolerance for missteps, and clear protocols for joint investigations and resolutions.

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.

Among patients with chest pain, the implementation of a comprehensive communication-and-resolution program was associated with substantially reduced growth rates in the use of diagnostic testing and imaging services. Further research is needed to establish to what extent these changes were attributable to the program and clinically appropriate.

This study analyzed if a communication-and-resolution program (CRP) was effective in lowering adverse events among patients with chest pain, as well as lowering medical costs. The study concluded that the implementation of the CRP was efficient, since it helped increase the number of chest pain diagnoses as well as significantly reduced associated health costs.

The rapid rate of change in the world of management continues to escalate. New government regulations, new products, growth, increased competition, technological developments, and an evolving workforce compel organizations to undertake at least moderate change on a regular basis. Yet few major changes are greeted with open arms by employers and employees; they often result in protracted transitions, deadened morale, emotional upheaval, and the costly dedication of managerial time. Kotter and Schlesinger help calm the chaos by identifying four basic reasons why people resist change and offering various methods for overcoming resistance.

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.

The Communication and Resolution Program (CRP) Certification program is a promising example of collaboration among institutions, insurers, and regulators to promote patient‐centered accountability and learning following adverse events in the healthcare setting. These programs are successful, because they promote transparency among patients after an adverse health incident, and increase overall health quality.

Colorado Candor Act: ARTICLE 51 Communication and Resolution After an Adverse Health Care Incident (2019)

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

The Collaborative for Accountability and Improvement Program is currently based at the University of Washington. The goal of the Collaborative is to bring 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. This CRP (Communication and Resolution Program) brochure describes CRP Core Commitments, Key Steps in the CRP Process and Launching a CRP.

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. In this study, CRP participants were interviewed. They identified several factors that contributed to their programs’ success, including the presence of a strong institutional champion and investing in building and marketing the program to skeptical clinicians.

This article explains how communication-and-resolution programs (CRPs) are successful in decreasing litigation fees and compensation that results from patient harm. However, the success of CRPs depends on patient satisfaction, making it necessary for healthcare professionals to focus on factors that increase this. Even though there is little evidence to support the idea that CRPs reduce adverse medical events that result in patient harm, these programs do have the potential to do so.

The Comprehensive Unit-based Safety Program (CUSP) was created by Johns Hopkins University 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 front line caregivers with the tools and support that they need to tackle the hazards that threaten their patients. This program has been used to target a wide range of problems, such as patient falls, hospital-acquired infections, and medication administration errors.

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.

COPIC is an insurance company that covers medical liability expenses. The company developed the 3Rs (Recognize, Respond, and Resolve) Program to prevent adverse events and increase patient safety. The goals of the 3Rs Program are 1) to maintain a healthy and professional relationship between the  physician and patient, 2) foster honest conversation, and 3) reimburse the patient for pertinent medical fees.

Researchers reviewed patterns in healthcare policies and trends in five countries (the United States, the United Kingdom, New Zealand, Australia, and Canada) with histories of disclosing adverse incidents to patients. The researchers wanted to analyze the barriers that prevent healthcare providers and institutions from disclosing adverse events to their patients. They concluded that some barriers included difficulties with liability fees, patients’ beliefs on safety in the healthcare setting, and implementing policy changes on a large-scale. Effective ways to combat these challenges include carrying out a long-term program that involves educating patients and healthcare workers about safety.

This article dissects the meaning of “disclosure-and-resolution” programs, which call health organizations to disclose medical errors to patients and families involved; apologize; and offer compensation when necessary. Health systems that used approach found decreased litigation fees. Researchers analyzed surveys in which individuals used “disclosure-and-resolution programs where appropriate. They found that increasing compensation allowances following an adverse event did not improve results, nor did it decrease the likelihood of patients and families filing lawsuits following an adverse event. Thus, it is important for healthcare systems to remember that “disclosure-and-resolution” programs may help promote effective and honest communication between patients and families, but it does not decrease associated legal costs or the possibility of a lawsuit.

Healthcare providers use root cause analysis to learn from malpractice and decrease the risk of adverse events. This method involves identifying the basic factors that cause performance variability. This model has three parts: 1) what occurred, 2) why did it occur, and 3) what strategies can be used to prevent the event from occurring in the future? This method is effective, because it helps healthcare providers identify the underlying causes of adverse events and take the necessary approaches to combat them.

Communication-and-resolution programs (CRPs) are implemented in hospitals to increase patient safety and effective communication between healthcare providers following patient injury. CRPs act as a guide for hospitals to disclose information to patients after medical injury, ways to efficiently investigate the incident, and how to take accountability for the event and offer compensation when appropriate. In this study, the authors analyzed the effectiveness of CRPs in reducing patient harm four Massachusetts health systems. The authors found that CRP implementation were correlated with decreased litigation fees, but they did not alter any other pertinent outcomes, such as reducing patient harm and increasing transparent communication.

Ernest Amory Codman MD (1869–1940) was a Boston surgeon who created a system in which he followed up with each of his patients years after hospitalization and recorded the end results of their care, including any errors in diagnoses and treatment. Dr. Codman then analyzed these errors and the correlation to patient health outcomes, and used them to make future improvements to not only increase patient safety but to excel as a healthcare provider.

Radiology’s leaders in peer review, patient-centered care, quality and safety, legal affairs, and institutional processes can help prepare radiologists to communicate openly with patients and families about errors by spearheading dialog within the profession regarding how best to implement this emerging practice standard.

The Handbook of Human Factors and Ergonomics in Health Care and Patient Safety offers a detailed overview of ergonomics and and human factors, theories, methods, and models that are pertinent to patient care and safety. Specific topics included in this book include telemedicine, infection prevention, and anesthesia safety.

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 object of this report is 1) to describe how hospitals use incident reporting systems and incident reports, 2) to determine the extent to which hospital incident reporting systems capture patient harm that occurs within hospitals, and 3) to determine the extent to which accrediters review incident reporting systems when assessing hospital compliance with Federal requirements to track instances of patient harm.

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. To make these programs more successful, legal entities should support them. State and federal policy makers should try to allay potential defendants’ fears of litigation, facilitate patient participation, and address the economic concerns of health care providers.

The existing structures and processes that together form an organization’s operating system need an additional element to address the challenges produced by mounting complexity and rapid change. The solution is a second operating system, devoted to the design and implementation of strategy, that uses an agile, network-like structure and a very different set of processes. The new operating system continually assesses the business, the industry, and the organization, and reacts with greater agility, speed, and creativity than the existing one. It complements rather than overburdens the traditional hierarchy, thus freeing the latter to do what it’s optimized to do. It actually makes enterprises easier to run and accelerates strategic change. This is not an “either or” idea. It’s “both and.” I’m proposing two systems that operate in concert.

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.

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 Agency for Healthcare Research and Quality (AHRQ) published the Communication and Optimal Resolution toolkit, which is a guide for the implementation of communication-and-resolution programs (CRPs). These are holistic and systematic methods for preventing and responding to adverse medical events involving patients. The toolkit also guides on how to promote sincere communication between patients, families and the healthcare team; appropriate financial compensation; and efficient ways to decrease future adverse medical events. The authors describe their personal experiences with applying CRPs in their medical practices in more than 200 hospitals. From their experiences, the authors describe the obstacles that prevented the success of CRP implementation, as well as how they overcame them.