Tools and Resources[ Show all or clear results ]

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.


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.


Journal Article
Published articles related to CRP
The Sorry Works! Coalition making the case for full disclosure.

The findings suggest that dividing healthcare conflict into relationship-based categories of conflict is appropriate due to significant differences in the types of conflict experienced in these dynamics and the corresponding differences in conflict management goals and interventions. Conflict management interventions in all of the four dynamics largely shared the aims of improving relationships, improving communication, and saving money, though each dynamic included additional aims.

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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.


The goal of the study was to determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes.

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Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
TJC Framework for Conducting a Root Cause Analysis and Action Plan

The Joint Commission’s Framework for Root Cause Analysis and Action Plan provides an example of a comprehensive systematic analysis. The framework and its 24 analysis questions are intended to provide a template for analyzing an event and an aid in organizing the steps and information in a root cause analysis.

Read more here.


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.


Journal Article
Published articles related to CRP
Transparency and the “end result idea”

Transparency was an issue for the American medical profession a century ago, and transparency is an issue for the American medical profession today. In 1905, Ernest Codman, MD, first described the “end result idea.”The end result idea is simply that doctors should follow up with all patients to assess the results of their treatment and that the outcomes actively be made public. The end result idea was considered heretical at the time, but in retrospect Codman was sagacious and prescient. He was an advocate for transparency, which he believed would promote quality improvement, patient choice, and physician learning. Transparency is best viewed as an opportunity, one that we should fully and enthusiastically embrace. It offers a substantive boost as organizations step up to the moral imperative of improving patient care to the best it can be.

Read more here.


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.

 

 


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Washington Foundation for Health Care Quality

The Foundation for Health Care Quality 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.

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Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors.

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Medicine safety culture is experiencing a bit of “aviation fatigue,” and it is often noted that patients are not airplanes. Patients are not airplanes, it is true. But humans are human whether they be pilots, physicians, or patients. And so when folks say a key difference between aviation and medicine is that the pilot goes down with the plane, I beg to differ. The well-being of physicians is directly tied to the well-being of their patients.

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Rebuttle to Patient Safety Takes a Back Seat, Once Again.

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