Tools and Resources[ Show all or clear results ]

Book/Report
Reference to book or report
Shining a Light: Safer Health Care Through Transparency

Report of the NPSF Lucian Leape Institute Roundtable on Transparency, 2015

Defining transparency as “the free flow of information that is open to the scrutiny of others,” this report offers sweeping recommendations to bring greater transparency in four domains: between clinicians and patients; among clinicians within an organization; between organizations; and between organizations and the public. It makes the case that true transparency will result in improved outcomes, fewer medical errors, more satisfied patients, and lowered costs of care.


BMJ Quality & Safety, 2009

Committing a medical error can cause profound emotional distress for clinicians, to the point that clinicians have been called the “second victim” of errors. This study examined how clinicians recover from the psychological stress of being involved in an error, and discusses the factors associated with recovery. A previous AHRQ WebM&M case commentary also explores how providers recover from such errors.


International Journal of Nursing Studies, 2013

One out of seven patients is involved in an adverse event. The first priority after such an event is the patient and their family (first victim). However the involved health care professionals can also become victims in the sense that they are traumatized after the event (second victim). They can experience significant personal and professional distress. Second victims use different coping strategies in the aftermath of an adverse event, which can have a significant impact on clinicians, colleagues, and subsequent the patients. It is estimated that nearly half of health care providers experience the impact as a second victim at least once in their career. Because of this broad impact it is important to offer support.

The focus of this review is to identify supportive interventional strategies for second victims.


Video
CRP related video, movie
The Lewis Blackman Story

This is a true story of a 15-year-old boy named Lewis Blackman who died in a hospital following routine surgery. This story has been taken from the Book “Wall of Silence” authored by Rosemary Gibson and Janardan Prasad Singh. The story can be found in Part One “Breaking the Silence”-“The Human Face of Medical Mistakes” page no-31.


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.
The Michigan Model: Medical Malpractice and Patient Safety at UMHS

University of Michigan Health System’s approach to medical errors and malpractice claims.

From the website:

“Since 2004, the U-M Health System has been in the national spotlight for its innovative approach to medical errors, mishaps and near-misses — and their potential legal consequences including malpractice suits. We call it the Michigan Model.

You may have heard something about our policy of “saying sorry”, or apologizing and having an open discussion, when clinical care does not go as planned. And while apologies are certainly part of our approach, there’s much more to it than that. Communication, full disclosure, and learning from our experiences are all vital.

You may have also heard that we have steadily reduced the number of malpractice claims pending against us and our doctors, slashed our malpractice expenses, dramatically dropped the amount paid to plaintiffs as a result of judgments or settlements, and cut the time it takes to handle a claim. All of this is true.”


Journal Article
Published articles related to CRP
The Second Victim of Adverse Health Care Events, Nursing Clinics

Article from Nursing Clinics, 2012

Nurses and other professionals drawn to health care by their desire to help others may be traumatized because they are involved in situations that bring harm rather than healing to patients. Health systems should develop early warning systems to alert unit or team leaders when health workers are at risk of harm from adverse events. This article focuses on health professionals who become second victims of adverse events that occur to patients.


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.
The second victim phenomenon: A harsh reality of health care professions

AHRQ PSNet, Perspectives on Safety, May 2011, Susan D. Scott RN, MSN

Article about impact of adverse events on caregivers and need of institutions to recognize and address the phenomenon.


Video
CRP related video, movie
The Story of Michael Skolnik

Michael Skolnik lost his life as a result of medical error. The error deals with transparency between the surgeon, patient and family regarding the necessity of the procedure and the surgeon’s experience or lack thereof.

The first video describes the event. This video is part of Medstar’s Patient Safety and Quality program.

The second video discusses shared decision making and transparency, beginning with informed consent. This video was produced for Transparent Health’s series “The Faces of Medical Error: From Tears to Transparency.”


Journal Article
Published articles related to CRP
The University of Michigan’s early disclosure and offer program.

Communication-and-resolution programs: the challenges and lessons learned from six early adopters. Mello MM, Boothman RC, McDonald T, Driver J, Lembitz A, Bouwmeester D, Dunlap B, Gallagher T. Health Aff (Millwood). 2014 Jan;33(1):20-9. doi: 10.1377/hlthaff.2013.0828.


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.
TJC Patient Safety Systems Chapter, Sentinel Event Policy and RCA2

The RCA2: Improving Root Cause Analyses and Actions to Prevent Harm describes methodologies and techniques that an organization or individuals can credibly and effectively use to prioritize the events, hazards, and vulnerabilities in their systems to understand what and why the event occurred, and how to prevent future events.


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.
University of Missouri’s ForYou and Caring for the Caregiver

University of Missouri’s forYOU team has been recognized nationally as a leader in supporting their caregivers. They are often contacted by health care providers outside MU Health Care who would like to learn more about their research or use their materials as a model for developing similar programs.


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.
VA National Center for Patient Safety

The NCPS’s website is a good source for toolkits, resources and event analysis methods.

The NCPS program is based on a systems approach to problem solving that focuses on prevention, not punishment. NCPS uses human factors engineering methods and applies concepts from high-reliability organizations, such as aviation, to target and eliminate system vulnerabilities.