Resources for patients and families in need of information and support after a medical error or adverse medical event.

Resources for clinicians and staff looking for data and information about the importance of support after adverse medical events, or for administrators that are interested in implementing a peer support program at their institution.

Webinar presented by Dr. Tom Gallagher on Thursday, June 6, 2019

Large-scale adverse events, situations in which a breakdown in care has affected multiple (sometimes thousands) of patients, pose significant challenges for institutions related to responding in ways that inform potentially affected patients without unduly alarming them and managing the follow-up. This webinar will highlight lessons learned from the field around responding effectively to adverse events, as well as key unanswered questions.

Learning objectives:

1. Describe the diversity of large-scale adverse events, and how responding to these events differs from managing adverse events that affect individual patients
2. List the key elements of an effective response to a large-scale adverse events and the tools that are currently available to assist with this process
3. Critique an actual large-scale adverse event patient notification letter and press release, and articulate opportunities for improvement in these documents.

The Comprehensive Unit-based Safety Program (CUSP) was created by Johns Hopkins University 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 front line caregivers with the tools and support that they need to tackle the hazards that threaten their patients. This program has been used to target a wide range of problems, such as patient falls, hospital-acquired infections, and medication administration errors.

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.

VitalTalk has released the COVID Ready Communication Skills resource to help healthcare professionals navigate COVID-19 related conversations with their patients and families.

VitalTalk is a Seattle based nonprofit organization that provides resources and training for health care clinicians in effective communication.

Researchers reviewed patterns in healthcare policies and trends in five countries (the United States, the United Kingdom, New Zealand, Australia, and Canada) with histories of disclosing adverse incidents to patients. The researchers wanted to analyze the barriers that prevent healthcare providers and institutions from disclosing adverse events to their patients. They concluded that some barriers included difficulties with liability fees, patients’ beliefs on safety in the healthcare setting, and implementing policy changes on a large-scale. Effective ways to combat these challenges include carrying out a long-term program that involves educating patients and healthcare workers about safety.

This guide for Getting Started with a CRP Policy or Commitment Statement outlines key elements and suggestions for developing an institutional CRP policy or commitment statement. It was developed by members of CAI’s Policy Committee in partnership with patient and family advocates.

Sidney Dekker, PhD supervises the Safety Science Innovation Lab at Griffith University in Brisbane, Australia. In Dekker’s book, Just Culture: Restoring Trust and Accountability in Your Organization (3rd ed.), he discusses how to effectively create a just culture of accountability and responsibility. This includes learning strategies on how to appropriately approach adverse incidents such that knowledge is maximized and the negative effects are minimized.

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.

The Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) created the Communication, Apology, and Resolution (CARe) Approach. This strategy aims to further patient safety by fostering honest communication, apologies, and just compensation in adverse situations. MACRMI partners with patient advocacy organizations to to teach health insurers and hospitals about this strategy.

The University of Michigan Health System (UMHS) systematically adopted the “open disclosure with offer” model, a principle-based strategy that emphasizes honesty and disclosure, to effectively respond to adverse patient outcomes and healthcare malpractices. When the UMHS adoped this model, there was a gradual reduction in litigation fees and the number of malpractice and patient harm claims.

Alberta Health Services (AHS) adopted the Patient and Family Centered Care (PFCC) program to increase patient and family engagement in the healthcare settings. The PFCC encourages and trains patients, families, and healthcare workers to share their experiences and improve care. This program also offers methods to measure the effectiveness of this program.

A Guide to Assist Health Departments and Healthcare Facilities with Conducting a Patient Notification Following Identification of an Infection Control Lapse or Disease Transmission

Patients and family members identified the factors that contributed to their respective adverse incidents, such as not following safety measures and lack of communication. Participants stated that they were not involved in the analysis process of the adverse events, so they missed out on ways to become more involved in learning about adverse events and how they can be decreased in the healthcare setting. Thus, the authors of this article emphasize that healthcare systems should implement educational modules that not only help decrease the risk of adverse events, but also teach healthcare professionals, patients, and family members on how to be proactive in preventing them.

In this study, conference and process leaders were divided into three groups Morbidity and Mortality Conferences (MMCs), Educational Conferences, and Quality Assurance (QA) Meetings) to review adverse incidents and near misses, as well as to find ways to prevent them in the future as well as to promote patient safety. Researchers found that it is important to incorporate various approaches and clinical practices to effectively promote patient safety in the healthcare setting.

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.

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.

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.

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.

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.

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.

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.”

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.

University of Michigan Health System developed the Michigan Model. This approach involves reducing and acknowledging medical errors through open communication between the patient and health institution, peer-reviewing the complaints to analyze the cause of the adverse event and how to prevent it in the future, and meeting with the patient and legal counsel to discuss the adverse event. With these implementations, the University of Michigan Health System successfully helped reduce the number of malpractice accusation against physicians, medical error fees, and total time it takes to manage a malpractice claim. Thus, the University of Michigan Health System is a leading innovator in increasing patient care and safety while also decreasing the adverse outcomes associated with medical malpractices.

This article discusses on how healthcare professionals are often considered “second victims” of adverse medical events, due to the psychological and emotional trauma they experience. To support second victims, it is important for health institutions to implement early warning systems that address harm risks associated with adverse incidents. In this article, researchers specifically focus on nurses and how respond to adverse medical events.

The Joint Commission’s Framework for Root Cause Analysis (RCA) and Action Plan offers a holistic outline of questions used for healthcare organizations to analyze adverse events in the workplace. Questions include identifying specific protocols in the procedure, external factors, staffing numbers, and other factors that could have potentially influenced the adverse outcome.

The Joint Commission published three reports that address patient care and reducing risks of adverse health outcomes: the Patient Safety Systems , Sentinel Event Policy, and RCA2. The Patient Safety Systems report explains how healthcare professionals can develop effective measures to promote patient safety and compassion towards coworkers. The Sentinel Event Policy report details how the Joint Commission collaborates with healthcare institutions to promote patient safety and improve systems that reduce the risk of adverse incidents. The RCA2: Improving Root Cause Analyses and Actions to Prevent Harm report illustrates strategies that institutions or individuals can utilize to analyze the hazards and faults in their systems to they can effectively prevent future adverse medical outcomes.

The goal of the VA National Center for Patient Safety (NCPS) is to offer tool kits, resources, and event analysis methods to help promote patient safety. The NCPS program is based on a systems approach to problem solving that focuses on prevention, not punishment. The organization uses human factors engineering methods and applies concepts from high-reliability organizations, such as aviation, to target and eliminate system vulnerabilities.