Tools and Resources[ Show all or clear results ]

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.


A well-designed, coordinated process across all clinical areas that incorporates accepted approaches for event analysis may improve the quality and safety of patient care.

Read more here.


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.
PSNet: Root Cause Analysis

Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care.

Read more here.


Journal Article
Published articles related to CRP
Psychological Safety and Error Reporting Within Veterans hospitals

In psychologically safe workplaces, employees feel comfortable taking interpersonal risks, such as pointing out errors. Previous research suggested that psychologically safe climate optimizes organizational outcomes. We evaluated psychological safety levels in Veterans Health Administration (VHA) hospitals and assessed their relationship to employee willingness of reporting medical errors.

Read more here.


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.


We found that an organizational culture characterized by anonymity, rewards and recognition for staff members making reports, grassroots involvement in the review and interpretation of data, and use of external sources of error data is critical for establishing a process truly capable of creating safety. This process for changing culture can be applied in any health care system desiring to improve the safety of the medication use process.

Read more here.


Education and engagement of all stakeholders of health care and negotiation of their conflicting goals will be necessary to change the balance of barrier incentives in favour of implementing reporting systems.

Read more here.


The objective of the study was to describe the litigation experience in a state with strict tort reform of a large public university health system that has committed to transparency with patients and families in resolving medical errors.

Read more here.


Journal Article
Published articles related to CRP
Respectful Management of Serious Clinical Adverse Events

A serious clinical adverse event is a crisis for everyone involved. Governing bodies and executive leadership carry the burden of these events forever, but carrying the burden isn’t enough. They also have a responsibility to ensure that everything possible is done to understand what happened and why it happened, and to prevent it from ever happening again. These crises have the power to be used to transform the organization to a dramatically better one. The individuals and organizations referenced in Acknowledgements, Appendix D, and the references in this white paper help to show us the way. This is the values-based “true north” of respectful management of serious clinical adverse events—the response that leaders would want for themselves and those they love. Health care leaders owe their patients, family members, staff, and community nothing less.

Read more here.


Significant evidence is mounting in support of patient engagement as a vital contributing component of safe care. This report is a call to action for health leaders, clinicians, and policy makers to take the necessary steps to ensure patient and family engagement at all levels of health care. The report identifies specific recommended action items for health leaders, clinicians, and policy makers to pursue in making patient and family engagement a core value in the provision of health care.

Read more here.


Journal Article
Published articles related to CRP
Saying “I’m Sorry”: Error Disclosure for Ophthalmologists.

This commentary spotlights elements of ophthalmology practice that can influence error disclosure, particularly the prevalence of patients receiving care from optometrists outside the hospital environment with no central reporting mechanism.

Read more here.


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.


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.


Journal Article
Published articles related to CRP
Slow Ideas, Atul Gawande

Some innovations spread quickly. Atul Gawande asks, How do you share the ones that don’t?

Read more here.


Streamed live on May 6, 2015 Clinicians encounter many stressors during their careers, none more significant than a difficult patient event that results in harm. Acknowledging that clinicians make seldom use of traditional support services, leading health centers across the US are pioneering Peer Support Programs that make available a trained and compassionate network of peers who can reach out and provide 1:1 support to a clinician experiencing stress.

In this live video event, we are honored to host the leading authority in the field, Dr. Jo Shaprio of Brigham and Women’s Hospital and Harvard Medical School, in conversation with Dr. Bryan Bohman, physician leader of Stanford Medicine’s Peer Support Program, to explore the following questions:

• What is motivating leading institutions to establish Peer Support Programs?
• How do Peer Support Programs work? How do they differ from existing support services?
• How effective are they? What do the data say?
• What best practices have emerged?
• What challenges need to be overcome?

The Risk Authority – Stanford, in partnership with Aon Risk Solutions, Lockton UK and MedPro Group invite you to participate in this exciting opportunity to learn about and explore Peer Support Programs from leading experts in the field.

Read more here.


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.


The Charter on Medical Professionalism, endorsed by more than 100 professional groups worldwide and the US Accreditation Council for Graduate Medical Education, requires openness and honesty in physicians’ communication with patients. We present data from a 2009 survey of 1,891 practicing physicians nationwide assessing how widely physicians endorse and follow these principles in communicating with patients. The vast majority of physicians completely agreed that physicians should fully inform patients about the risks and benefits of interventions and should never disclose confidential information to unauthorized persons. Overall, approximately one-third of physicians did not completely agree with disclosing serious medical errors to patients, almost one-fifth did not completely agree that physicians should never tell a patient something untrue, and nearly two-fifths did not completely agree that they should disclose their financial relationships with drug and device companies to patients. Just over one-tenth said they had told patients something untrue in the previous year. Our findings raise concerns that some patients might not receive complete and accurate information from their physicians, and doubts about whether patient-centered care is broadly possible without more widespread physician endorsement of the core communication principles of openness and honesty with patients.

Read more here.


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

The Beryl Institute is the global community of practice dedicated to improving the patient experience through collaboration and shared knowledge. We define patient experience as the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.

Read more here.


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
The Collaborative for Accountability and Improvement

The Collaborative for Accountability and Improvement is a network of the physicians, attorneys, and insurers who pioneered the earliest CRPs in the United States. It is our belief that CRPs are an essential strategy for preventing medical errors and cultivating high-quality, patient-centered healthcare. Our mission is to radically accelerate the adoption of CRPs nationally and internationally, particularly through education, training, and hands-on support. We are housed at the University of Washington.

Read more here.


Book/Report
Reference to book or report
The field guide to understanding’human error

When faced with a ’human error’ problem, you may be tempted to ask ‘Why didn’t these people watch out better?’ Or, ‘How can I get my people more engaged in safety?’ You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of ‘The Bad Apple Theory’ where you believe your system is basically safe if it were not for those few unreliable people in it. Building on its successful predecessors, the third edition of The Field Guide to Understanding ’Human Error’ will help you understand a new way of dealing with a perceived ‘human error’ problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call ‘human error’, allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding ‘Human Error’ will help you understand how to move beyond ‘human error’; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization. If you are faced with a ’human error’ problem, abandon the fallacy of a quick fix. Read this book.

Read more here.


Journal Article
Published articles related to CRP
The hard side of change management.

We completed our study in 1994, and in the 11 years since then, the Boston Consulting Group has used those four factors to predict the outcomes, and guide the execution, of more than 1,000 change management initiatives worldwide. Not only has the correlation held, but no other factors (or combination of factors) have predicted outcomes as well.

Read more here.


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 human side of medical errors.

Decide when it is safe and ethical to provide medical care to close friends or coworkers. Respond constructively to the emotional impact caused by an adverse outcome in one of your patients. Share bad news with patients or families compassionately and effectively. Participate in safe and efficient patient handoffs with other healthcare providers. Recognize and respond appropriately to disruptive behavior that is endangering patient safety within the health care team.

Read more here.


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.”


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.

Read more here.


Journal Article
Published articles related to CRP
The path to safe and reliable healthcare

This commentary describes a model that aims to improve health care quality by analyzing potential risks, recommending actions, and sustaining improvements.

Read more here.


Journal Article
Published articles related to CRP
The science of human factors separating fact from fiction

The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities.

Read more here.