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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 systematic method used to analyze adverse incidents, especially in the healthcare setting. This approach identified both active and latent errors that contribute to adverse incidents. Active errors occur between humans and the system, while latent errors are known as the hidden issues in a healthcare system. An important principle of RCA is to recognize the source of problems that contribute the increased risk of medical errors, while not concentrating on individual mishaps as the sole cause of the issue.



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

Previous studies suggest that psychologically safe workplaces foster a feeling of comfort among employees, allowing them to feel comfortable with taking risks, such as identifying mistakes in the workplace. In this study, researchers analyzed the levels of psychological safety in Veterans Health Administration (VHA) hospitals, and studied its relationship to employees’ comfort in disclosing medical mistakes. Researchers found that only a minority of workers were uncomfortable in admitting mistakes, and their discomfort was due to fear of retaliation.


Journal Article
Published articles related to CRP
RCA2: Improving root cause analyses and actions to prevent harm

The National Patient Safety Foundation (NPSF) published this report on root cause analyses and actions (“RCA2”), which are programs aimed to reduce the risk of adverse medical events and instead increase effective measures to reduce them in the future. This report illustrates strategies that healthcare organizations can utilize when implementing RCA2 programs in the workplace. This report also details specific strategies that help healthcare organizations identify the faults and hazards in their systems that increase the risk of adverse medical outcomes, as well as how to take active and positive steps to prevent them from happening in the future.



Reference to book or report

The National Patient Safety Foundation conducted a study to investigate the effectiveness of root Cause Analyses and Actions, or RCA2 (RCA “squared”), in healthcare settings. RCA2 is a model used by health professionals to understand why mistakes occur in the workplace, and how to develop strategies to prevent them in future situations. National Patient Safety Foundation specifically concentrated on the specific methods used by the RCA2 model, and analyzed if they were effective or not. They also identified defects in the model and sought out ways on how to improve them, so they model could be efficient.


Researchers concluded 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.


The authors of this article analyzed how medical mistakes and injuries are correlated with high healthcare costs and poor patient quality. To lower these rates, the authors emphasized the importance of implementing an incident reporting system in healthcare settings. The implementation of these systems involve changing the culture of the workplace, so it promotes learning, flexibility, and blamelessness.


The authors of this study analyzed the importance of healthcare professionals being transparent in medical malpractices with their patients in the Texas healthcare system. The authors found that medical mishap litigation helped significantly reduce suing and other damages. The authors also emphasized the importance for healthcare systems to work with attorneys, policy makers, and patients to help develop methods to be more transparent about medical mishaps and enforce proactive mediation.



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.


Audio recording, Podcast, etc.
RTE Radio 1 Interview with Jo Shapiro

Dr. Jo Shapiro of Brigham and Women’s Hospital is interviewed about disclosure, peer support, and resilience following medical error on Ireland’s national public radio, RTÉ Radio 1 (July 9, 2017).

The Institute for Healthcare Improvement (IHI) is an organization that aims to improve healthcare systems worldwide. The IHI published Safety is Personal: Partnering with Patients an Families for the Safest Care, a report on patient safety and quality. This report provides specific action steps for healthcare providers and policy makers to establish patient and family engagement in various dimensions of healthcare.


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.


Sidney Dekker, the author of Second Victim: Error, Guilt, Trauma, and Resilience, discusses how healthcare professionals are considered second victims in medical mishaps, because of the trauma and guilt they experience int the wake of these incidents. In his book, Dekker details efficient ways to investigate medically adverse events so that healthcare professionals do not feel neglected or more guilty in the process. Dekker also emphasizes the importance of having support systems in healthcare settings for second victims.


CRP resource or tool (e.g. CANDOR)
Serious Illness Care Program COVID-19 Response Toolkit

Serious Illness Care Program COVID-19 Response Toolkit by Ariadne Labs, first version was published on April 3, 2020.

Ariadne Labs, one of Collaborative for Accountability and Improvement’s partners in cultivating high-quality, patient-centered care, has developed the Serious Illness Care Program’s COVID-19 Response Toolkit to help clinicians with difficult conversations with high risk COVID-19 patients.

Table of Contents: 

  1. COVID-19 Conversation Guide for Outpatient Care
  2. Telehealth Communication Tips
  3. Recommendation Aid
  4. Care Planning Resources

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

The NPSF Lucian Leape Institute Roundtable on Transparency published “Shining a Light: Safer Healthcare Through Transparency,” a report focused on being honest in four healthcare settings: between healthcare workers and patients; between healthcare professionals and the institutions; between institutions; and between institutions and the greater public. Transparency is defined as “the free flow of information that is open to the scrutiny of others,” and it is related with better healthcare outcomes, decreased rates of medical mishaps, lower healthcare costs, and increased rates of patient satisfaction.


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.
Slow Ideas: Atul Gawande

Dr. Atul Gawande, general surgeon and part-time professor at Harvard University, analyzed the histories of various medical innovations, such as anesthesia and oral re-hydration therapy, and why they were successful or unsuccessful in swift diffusion. General obstacles included resistance from healthcare professionals, as well as weariness that the method was unsuccessful. However, general reasons why other methods were successful was because they combat the negative effects of germs and pain.


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.

In the BMJ Quality & Safety Study (2009), researchers studied why clinicians are often considered “second victims” in the wake of medical errors. The researchers delved into how healthcare providers recover from the guilt and stress involved medical errors, and discuss the elements related to recovery and delineate from the second victim phenomenon. These factors include moving forward, receiving emotional support, and reestablishing a sense of integrity. Researchers recommended that it is important to for healthcare institutions to implement support systems that not only offer emotional aid but also decrease the likelihood of future adverse events.




Researchers acknowledged how a majority of adverse medical events involve patient harm. Patients and family are known as first victims. Researchers also acknowledged how healthcare professionals are also considered victims after an adverse event, due to the emotional and psychological trauma experienced after it. In other words, healthcare professionals are also known as second victims. In this study, researchers analyzed the various coping strategies that clinicians use in the wake of adverse events. These strategies include attending programs that offer emotional aid second victims, as well as taking accountability for the situation and learning from it.


The Charter on Medical Professionalism, endorsed by the US Accreditation Council for Graduate Medical Education, requires physicians to engage in honest communication with their patients, especially regarding risks and benefits regarding medical procedures. However, researchers found that not all physicians abided by these rules which raises the concern that physicians may not fully disclose pertinent information with their patients, so they do not receive complete information. Honest communication between patients and their physicians is associated with patient comfort and willingness to move forward in medical procedures.


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

The Beryl Institute is a community of practice with the goals of improving patient care and experience though teamwork and share values. The institute define patient experience as the sum of all interactions, influenced by an institution’s culture, that impact patient perceptions of healthcare. Among the Beryl Institute’s various goals to improve patient experience and care, they are committed to prioritizing patients, families, and care providers first; emphasizing the importance of the entire healthcare team; and engaging a variety of perceptions and voices from various sectors.


In April 2012, Glenn Clarkson died after a medical error at a rural Kansas hospital. Melissa and Nancy Clarkson describe the three-and-a-half-years of work it took for them to learn what happened in his medical care. Filmed at the Communication and Resolution Program (CRP) Training.

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 based at the University of Washington, Seattle, composed of the physicians, attorneys, and insurers who pioneered the earliest CRPs in the United States. It is our belief that communication-and-resolution programs (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.

Journal Article
Published articles related to CRP
The Disclosure Dilemma — Large-Scale Adverse Events

Large-scale adverse events are individual events or a series of related events that injured or increased the risk that many patients would be injured because of health care management. There are ethical reasons why institutions may hesitate to disclose large-scale adverse events to patients. Practical, legal, and financial considerations, such as the difficulty in predicting the likelihood of harm and identifying the injured patients, may also lead well-meaning institutions to consider not disclosing large-scale adverse events. This article discusses two ethical frameworks often used in determining whether to disclose large-scale adverse events: utilitarian and duty-based. It also describes three examples of large-scale adverse events and discuss their distinguishing features.

Reference to book or report
The field guide to understanding ‘human error’

In The Field Guide to Understanding ‘Human Error,’ Sidney Dekker discusses how organizations can successfully deal with perceived “human error” without implementing new rules, punishing people, or requesting compliance. Dekker discusses how people embody “the Bad Apple Theory,” which states that an institution would be safe and reliable albeit a few irresponsible individuals in it. To combat this theory and “human error,” Dekker encourages organizations to learn to understand mistakes, how to improve investigative processes, and how to increase the safety climate of the workplace. He does this by offering specific strategies that encourage organizations and employees to think creatively to foster a safe environment that mitigates “human error.”


This report from the Betsy Lehman Center details two sets of research findings and proposes a coordinated response through which Massachusetts’s providers, policymakers, and public can accelerate safety and quality improvement and lead the nation on this urgent health care challenge.

Healthcare professionals are reluctant to apologize for medical errors, because they fear it could be used against them in lawsuits. In response to this issue, some states are developing policies that legally protect physicians, so they feel more comfortable apologizing to patients involved in medical errors. Even though these policies seem beneficial in theory, researchers found that these laws could discourage apologies and honest communication between patients and physicians following adverse medical events. Thus, researchers emphasize the importance for states to develop policies with modified legal protections and implications to not only promote disclosure between patients and physicians following adverse medical incidents, but also do not weaken the legal influence on lawsuits involving malpractice.

Journal Article
Published articles related to CRP
The Handbook of Communication and Social Interaction Skills

The Handbook of Communication and Social Interaction Skills is a holistic guide that draws form theories and surveys to improve communication and social interaction skills in various environments and settings. This handbook is divided into five sections: theoretical and methodological concepts (gaining and assessing skills); basic social interaction skills; persuading, informing, and supporting skills; various relationship skills (marriages, friendships, and romances); and skills necessary for public leadership and management (teaching and supervising).

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

Authors of this article discuss how hard factors act as obstacles in change management. Hard factors have three characteristics: 1) Corporations can measure them in implicit and explicit ways, 2) corporations can communicate these factors both within in and outside of organizations, and 3) corporations can rapidly influence the previous elements. Authors emphasize that it is necessary for businesses to prioritize the hard factors before they can move forward and improve.

Journal Article
Published articles related to CRP
The Impact of Adverse Events on Clinicians: What’s in a Name?

The authors of this article discuss how physicians are dubbed “second victims,’ due to the negative emotional and psychological challenges they experience as a result of patient adverse incidents. The authors also illustrate how the term “second victim” can be a harmful term, since it implies passivity and mitigates the experiences of patients and families also affected by medical errors. It is argued that this term points to the necessity of healthcare institutions to implement support programs to help physicians heal and cope following the negative effects of adverse health outcomes.

CRP related video, movie
The Lewis Blackman Story – YouTube Video

This YouTube video recounts the true story of Lewis Blackman, a 15-year-old boy who died in a hospital following routine surgery. This story sheds light on the importance of healthcare providers to not only be cognizant of their patients’ conditions,  but to also frequently engage with families so they feel involved in patient care.

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.