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)

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.

OBJECTIVES: There is a growing expectation in health systems around the world that patients will be fully informed when adverse events occur. However, current disclosure practices often fall short of this expectation. METHODS: We reviewed trends in policy and practice in 5 countries with extensive experience with adverse event disclosure: the United States, the United Kingdom, Canada, New Zealand, and Australia. RESULTS: We identified 5 themes that reflect key challenges to disclosure: (1) the challenge of putting policy into large-scale practice, (2) the conflict between patient safety theory and patient expectations, (3) the conflict between legal privilege for quality improvement and open disclosure, (4) the challenge of aligning open disclosure with liability compensation, and (5) the challenge of measurement related to disclosure. CONCLUSIONS: Potential solutions include health worker education coupled with incentives to embed policy into practice, better communication about approaches beyond the punitive, legislation that allows both disclosure to patients and quality improvement protection for institutions, apology protection for providers, comprehensive disclosure programs that include patient compensation, delinking of patient compensation from regulatory scrutiny of disclosing physicians, legal and contractual requirements for disclosure, and better measurement of its occurrence and quality. A longer-term solution involves educating the public and health care workers about patient safety.

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.

Ernest Amory Codman MD (1869–1940) was a Boston surgeon. Like all of us, he was human and made mistakes. Unlike others, he made a lifelong systematic effort to follow up each of his patients years after treatment and recorded the end results of their care. He recorded diagnostic and treatment errors and linked these errors to outcome in order to make improvements. Read about how Ernest transformed medicine based on evidence and accountability.

Read more here.

The first edition of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety took the medical and ergonomics communities by storm with in-depth coverage of human factors and ergonomics research, concepts, theories, models, methods, and interventions and how they can be applied in health care. Other books focus on particular human factors and ergonomics issues such as human error or design of medical devices or a specific application such as emergency medicine. This book draws on both areas to provide a compendium of human factors and ergonomics issues relevant to health care and patient safety.

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

The object of this report is to report the following: To describe how hospitals use incident reporting systems and incident reports. To determine the extent to which hospital incident reporting systems capture patient harm that occurs within hospitals. To determine the extent to which accreditors review incident reporting systems when assessing hospital compliance with Federal requirements to track instances of patient harm.

Read the rest here

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).

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, networklike 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.

Read the rest here.

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.

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.

Read the rest here.

The response to adverse events can lack patient-centeredness, 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.

Read the rest here.

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.

The Institute for Patient- and Family-Centered Care (IPFCC), a non-profit organization founded in 1992, takes pride in providing essential leadership to advance the understanding and practice of patient- and family-centered care. By promoting collaborative, empowering relationships among patients, families, and health care professionals, IPFCC facilitates patient- and family-centered change in all settings where individuals and families receive care and support.

Read more here.

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.

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.

Read more here.

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.

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 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. We hope that this study will encourage further disclosure efforts, as well as the detailed evaluation of their effects.

Read more here.

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.

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.

This article chronicles the adverse event that catalyzed the formation of Medically Induced Trauma Support Services (MITSS), a non-profit organization with a focus on emotional support in the aftermath of adverse events; the evolution of the organization over the past 11 years; and the development of a menu of support services. By providing a detailed discussion of common themes, shared emotions, long-term consequences, and effective interventions, we hope to inform a greater understanding of the patient/family experience when things go wrong in healthcare.

Read more here.

Slide decks and agenda for the two day CRP leadership retreat in Seattle, Washington hosted by The Collaborative for Accountability and Improvement and the Foundation for Healthcare Quality.

Program goals:

To present Northwest Hospitals to the CRP concept and introduce local and national resources available to help implement highly functioning CRPs.

To lay the groundwork for an alliance of CRP stakeholders (patients, attorneys, hospital leadership, and health insurers in conjunction with the Foundation for Healthcare Quality) committed to the practice and advancement of CRP in the Northwest.

Takeaways:

Define the core components of a CRP and why each component is critical to a CRP’s effectiveness

Describe the common barriers healthcare organizations experience when implementing a CRP and the strategies for overcoming them

Conduct a CRP gap analysis at their institution and interpret the results

Develop a plan for their organization to implement a CRP effectively

In mid-2001 and early 2002, the University of Michigan Health System systematically changed the way it responded to patient injuries and medical malpractice claims. Michigan adopted a proactive, principle-based approach, described as an “open disclosure with offer” model, built on a commitment to honesty and transparency. Implementation was followed by steady reduction in the number of claims and various other metrics, such as elapsed time for processing claims, defense costs, and average settlement amounts. Though the model continues to evolve, it has retained its core components and the culture it nurtured while spurring other initiatives such as a unique approach to peer review. In this article we review our experience, identify the essential practical components of our model, offer suggestions for tailoring the approach to other settings, and present some thoughts as to the future of this approach.

Read more here.

The Oregon Patient Safety Commission seeks to advance, support, and encourage patient safety in Oregon. By working to reduce the risk of patient harm and encourage a culture of patient safety through education, shared learning, and improved transparency, we are furthering our vision of safe healthcare for all Oregonians. We are a multi-faceted, semi-independent state agency created by the legislature in 2003 to further patient safety in the state. We operate multiple mission-driven programs, which include the Patient Safety Reporting Program, Early Discussion and Resolution, and various quality improvement initiatives.

See the resource here.

It is through the lessons of our everyday errors that we can design our work environment to be less error-prone and more error tolerant. Few people are willing to come forward and admit to an error when they face the full force of their corporate disciplinary policy, a regulatory enforcement scheme, or our onerous tort liability system. To collect productive investigative data, we must promote a culture in which employees are willing to come forward in the interests of system safety.

Read more here.

Patients/family members identified contributing factors related to their adverse event. Given that these contributing factors might not be known to health care organizations because most participants stated that they were not involved in the analysis process, opportunities for organizational learning from patients are potentially being missed.

Read more here.