This article discusses the negative connotations that surround the term “second victim,” which is used to describe healthcare providers following their involvement in a adverse medical incident. Authors of this article persuade people to stop using this term, since it discourages healthcare providers from taking responsibility for their actions, as well as undermines the patient’s feelings and situation.

The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of America’s health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions.

Incident reporting is the most common method used to promote patient safety in healthcare settings. This method requires those involved in the event go complete an incident form, which is a detailed summary of the occurrence. There are key components that make incident reporting systems effective and successful. To be successful, the incidence form should be submitted in a timely manner and be disseminated among an array of healthcare professionals.

Advances in Patient Safety: From Research to Implementation describes what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety over the last five years. This compendium is sponsored jointly by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD)-Health Affairs. The 140 articles in the 4-volume set cover a wide range of research paradigms, clinical settings, and patient populations. Where the research is complete, the findings are presented; where the research is still in process, the articles report on its progress. In addition to articles with a research and methodological focus, the compendium includes articles that address implementation issues or present useful tools and products that can be used to improve patient safety.

The Agency for Healthcare Research and Quality (AHQR) developed the CANDOR (Communication and Optimal Resolution) Event Checklist, which is a guide to be used by the CANDOR team after an adverse event occurred in the healthcare setting. The checklist includes effective ways of reporting, assessing, investigating, and analyzing the adverse event to decrease the likelihood of future incidents occurring, as well as improving the overall quality of patient care and safety.

The CANDOR Event Review Report Template is a guide used to analyze and investigate barriers that contributed to an adverse health event. Barriers include poor communication behaviors, unsafe physical environment, inadequate care, and equipment device failure. This template also includes a guide to assess who was responsible for the adverse event, and ways to develop solutions for it so it.

The Communication and Optimal Resolution (CANDOR) process is used  by health care institutions and practitioners to respond in a timely, thorough, and just way when unexpected events cause patient harm. The CANDOR toolkit contains eight different modules, which contain PowerPoint slides with facilitator notes, tools, resources, or videos. Examples of modules include “Care for the Caregiver” and “Organizational Learning and Stability.” These modules focus on effective ways to reduce patient harm and increase overall healthcare quality and safety through family and patient engagement, as well as specific ways to decrease the risk of future adverse outcomes.

The Guide to Patient and Family Engagement in Hospital Quality and Safety was developed by the for Healthcare Research and Quality (AHRQ) to encourage patient and family involvement in healthcare quality and safety. This guide includes four key methods as follows:

• Encourage patients and family members to participate as advisers.
• Promote better communication among patients, family members, and health care professionals from the point of admission.
• Implement safe continuity of care by keeping the patient and family informed through nurse bedside change-of-shift reports.
• Engage patients and families in discharge planning throughout the hospital stay.

Read how the AMA pursues medical liability laws on the state level to reshape the current medical liability system to better serve both physicians and patients.

“Annie’s Story” is an example of how healthcare organizations seeking high reliability embrace a just culture in all they do. This includes a system’s approach to analyzing near misses and harm events—looking to analyze events without the knee-jerk blame and shame approach of old. This video specifically focused on Nurse Andrea’s personal experience with an adverse health event with a patient who underwent a hypoglycemic emergency due to a misreading of a glucometer. The video then details the steps she and the hospital took to prevent future adverse health events, as well as other ways to increase overall patient safety and quality.

The authors discuss trends in the medical malpractice liability insurance market, consider the impacts COVID-19 has had, and suggest using a CRP approach during the pandemic to lessen the consequences of a hardening insurance market.

The Apology and Disclosure Grand Rounds NWH incorporates a video simulated error and a presentation about “When Things Go Wrong”. The presentation discusses disclosure coaching & peer support, the emotional impact of errors on clinicians, and principles for transparent & compassionate disclosure and apology.

39 states have apology laws, with over a third applying to healthcare or other contexts. After over a decade of experience with apology laws, the authors explore whether apology laws reduce malpractice liability risk and why, and whether there is a reason to have them.

Background
Many health care organizations want to improve their responses to patients who suffer medical injuries. Their ability to understand how well they meet patients’ needs is limited by the lack of suitable instruments for assessing injured patients’ experiences.
Methods
This study aimed to generate items for a patient experience questionnaire that medical facilities can use to assess how well resolution met patients’ needs. The Medical Injury Reconciliation Experiences Survey (MIRES) was based on findings from previous studies of New Zealand and American patients’ experiences of non-litigation resolution of medical injuries. The researchers performed a content analysis of 24 transcripts from a stratified random sample of 92 interviews from the prior studies. Themes were extracted to develop a draft questionnaire, which was revised following feedback from experts. Cognitive debriefing interviews were conducted with 24 New Zealand and American injured patients.
Results
There were 40 items in the following domains: perceptions of communications with health care providers after the injury (15 items), perceptions of remedial gestures (11 items), indicia of the patient’s overall satisfaction with the reconciliation process (4 items), the nature and impacts of the injury (5 items), and patients’ characteristics (5 items). Participants’ feedback about the questionnaire was predominantly positive. Their suggestions led to 37 revisions.
Conclusion
The MIRES was comprehensible and acceptable to this group of post-injury patients. While further testing is desirable, the MIRES offers promise as a practicable approach that health care organizations can use to assess how well their reconciliation processes met patients’ needs.

Medical errors are associated with significant emotional, financial, physical and sociobehavioural impacts including reduced trust and willingness to seek healthcare. These impacts can last for years. The study sought to understand whether greater open communication is associated with reduced emotional impacts and decreased avoidance of doctors/facilities involved in the error.

Background: The emotional impact of medical errors on patients may be long-lasting. Factors associated with prolonged emotional impacts are poorly understood.

Methods: The authors conducted a subanalysis of a 2017 survey (response rate 36.8% [2,536/6,891]) of US adults to assess emotional impact of medical error. Patients reporting a medical error were included if the error occurred ≥ 1 year prior. Duration of emotional impact was categorized into no/short-term impact (impact lasting < 1 month), prolonged impact (> 1 month), and especially prolonged impact (> 1 year). Based on their reported experience with communication about the error, patients’ experience was categorized as consistent with national disclosure guidelines, contrary to guidelines, mixed, or neither. Multinomial regression was used to examine associations between patient factors, event characteristics, and organizational communication with prolonged emotional impact (> 1 month, > 1 year).

Results: Of all survey respondents, 17.8% (451/2,536) reported an error occurring ≥ 1 year prior. Of these, 51.2% (231/451) reported prolonged/especially prolonged emotional impact (30.8% prolonged, 20.4% especially prolonged). Factors associated with prolonged emotional impact included female gender (adjusted odds ratio 2.1 [95% confidence interval 1.5–2.9]); low socioeconomic status (SES; 1.7 [1.1–2.7]); physical impact (7.3 [4.3–12.3]); no organizational disclosure and no patient/family error reporting (1.5 [1.03–2.3]); communication contrary to guidelines (4.0 [2.1–7.5]); and mixed communication (2.2 [1.3–3.7]). The same factors were significantly associated with especially prolonged emotional impact (female, 1.7 [1.2–2.5]; low SES, 2.2 [1.3–3.6]; physical impact, 6.8 [3.8–12.5]; no disclosure/reporting, 1.9 [1.2–3.2]; communication contrary to guidelines, 4.6 [2.2–9.4]; mixed communication, 2.1 [1.1–3.9]).

Conclusion: Prolonged emotional impact affected more than half of Americans self-reporting a medical error. Organizational failure to communicate according to disclosure guidelines after patient-perceived errors may exacerbate harm, particularly for patients at risk of health care disparities.

This article explains the challenge of balancing accountability and a “no blame” model in healthcare systems when promoting patient safety. Accountability is defined as taking responsibility for one’s actions. In this article, it is taking responsibility for malpractice that increases patient harm. the “no blame” model is defined as not accusing a single entity for any healthcare misconduct. It is important for healthcare systems to embody both taking responsibility for healthcare malpractices as well as the “no blame” model to effectively promote patient safety and quality and reduce adverse health events.

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 Date: January 21, 2021

Wesley R. Butler discusses the role of confidentiality and privilege within the context of Communication and Resolution Programs.

Presenter: Wesley R. Butler is an attorney at Barnett Benvenuti & Butler PLLC in Lexington Kentucky who focuses on advising health care providers on regulatory matters that implicate safety, quality, and reimbursement.

Objectives: 

• Outline the elements of typical confidentiality and privilege interests in patient safety and quality analyses, and explore the public policies that support such interests
• Outline the fundamental components of common CRP processes in health care, and explore the public policies and ethical considerations that support CRPs for responding to patient harm events
• Analyze the interplay between CRPs and confidentiality and privilege interests to identify complementary and divergent points
• Conclude with practical suggestions to illustrate that health care providers can fully implement CRP processes while respecting the boundaries of confidentiality and privilege and,  ultimately, gain the benefits that both perspectives offer

Webinar Date: April 26, 2022

Moderator

• Caitlin Harrington. MD, JD

Speaker Panel

• Jeffrey N. Catalano, JD
• Jeff Goldenberg, MD
• Naomi Kirtner
• Jo Shapiro, MD, FACS

Webinar Date: February, 2021

Overview: COVID-19 has fundamentally altered our care processes and standards.  Care is being delayed, visits are happening by telemedicine, there are changes in how staff are deployed and interact with patients, and everyone is exhausted and emotionally depleted. These all make potential for patient harm events higher.  COVID-19 is also adding stress to already tightening medical professional liability insurance market. While it may be tempting to abandon ship when it comes to implementing CRP during COVID-19 times, CRPs are more important now than ever.  Fundamental principles of the CRP model-supporting patients, families, and clinicians after harm with open communication, empathy, learning, and accountability – are critical elements of how we respond to COVID-related harm events.  This webinar examines two cases of COVID-associated adverse events to help lead a discussion on the challenging aspects in implementing CRPs during this time.

Presenters: Michelle Mello, JD, PhD, and Thomas H. Gallagher, MD

Commentary by: Jeffrey Catalano, JD, Marcia Rhodes, Jonathan Steward, JD, MS, RN-BC, CEN, CPHRM

Learning Objectives: 

• Examine potential communication and legal issues associated with COVID-related harm events
• Describe how CRPs can be used as a strategy to address these COVID-related adverse events
• Learn about CRP resources to help address COVID-related challenges

Webinar Date: June 24, 2021

Presenters:

Objectives:

Webinar Date: September 15, 2022

Presenters: Melinda B. Van Niel, MBA, CPHRM

Melinda B. Van Niel, M.B.A., C.P.H.R.M., has been working to help resolve adverse events through Communication Apology and Resolution (CARe) for ten years. She is the Director of CARe programs at the Betsy Lehman Center for Patient Safety in Massachusetts (formerly MACRMI) leading its implementation team, and consults on CARe implementation for institutions across the country. In the past she worked as the Manager of Patient Safety at Beth Israel Deaconess Medical Center in the department Healthcare Quality where she helped build one of the first CARe programs in the state, and was a contributor and advisor to the AHRQ’s CANDOR Toolkit. Ms. Van Niel received her Bachelor of Arts degree from Harvard University and her Master’s in Business Administration from Villanova University with a concentration in healthcare management.

Webinar Date: September 23, 2021

Presenters: 

• Alan Lembitz, MD, MMM, Chief Medical Officer, COPIC
• Eric Wei, MD, MBA Senior Vice President and Chief Quality Officer, NYC Health + Hospitals
• Laurie C. Drill-Mellum, MD, MPH, Chief Medical Officer, Constellation

Learning Objectives:

• Understand the importance of physician involvement in the CRP process and how it helps both physicians and patients
• Examine the benefits of CRPs to physicians
• Explore the barriers to CRP implementation from a provider’s perspective
• Learn why psychological safety a critical component of provider support

Webinar Date: May 20, 2021

Moderator:

• Barbara Pelletreau, RN, MPH, Senior Vice President, Patient Safety, CommonSpirit Health

Speaker Panel:

• Claire Hagan, MJ, CPHRM Director of Risk Management Programs, Providence St. Joseph Health
• Brittnie Hayes, JD, Claims Manager, COPIC
• Linda Ubaldi, RN, CANDOR Training Specialist and Former Quality and Patient Safety Officer, CommonSpirit Health

Learning Objectives:

• Learn practical advice from “claims professionals” on how to transition a CRP case to claims
• Describe several of the key components for an ideal partnership and transition to claims from the perspectives of health systems, insurers, and patients and families
• Understand the needs of patients and families, and how and when to appropriately engage them, in this transition to “claims process”

Webinar Date: June 17, 2021

Presenters: Jonathan D. Stewart, JD, MS, RN-BC, CPHRM

Jonathan is a Senior Director of Risk Management and Patient Safety at BETA Healthcare Group, where he serves as a consultant to hospitals, health care facilities and medical groups. His current professional focus includes helping health care organizations operationalize communication and resolution programs, particularly the investigation and analysis of patient harm events.

Objectives:

• Identify conflicting notions of success and failure regarding CRPs
• Discuss the relationship between incomplete CRP implementation and irregular application of CRPs
• Describe lessons learned from unsuccessful applications of CRPs to individual events

Webinar Date: March 17, 2022

Moderator

• Caitlin Harrington. MD, JD

Speakers

• Dr. Jeff Goldenberg and Naomi Kirtner, co-founders of Talia’s Voice

Webinar Date: October 21,2021

Moderator

• Carole Hemmelgarn, MS, MS

Speaker Panel

• Jack and Teresa Gentry
• Naomi Kirtner and Jeff Goldenberg, MD

Learning Objectives

• Understand what elements are important for patients and families to hear after medical harm
• Compare and contrast patient experiences with and without a Communication and Resolution Program (CRP) following harm
• Explain the importance of a highly reliable CRP for patients and families

Webinar Date: October 12, 2022

Presenter: WilliamM.  Sage, MD, JD

William M. Sage, MD, JD, an authority on health law and policy, is a tenured professor in Texas A&M’s medical and law schools, a professor by courtesy in the Bush School of Government and Public Service at Texas A&M, and a vice president in the university’s Health Science Center.   From 2006-2022, he held professorships in law and medicine at the University of Texas at Austin, where he also served as vice provost for health affairs.  He was previously a tenured professor at Columbia Law School, and has been a visiting professor at Yale, Harvard and NYU.  Prof. Sage is a member of the National Academy of Medicine, where he serves on the Board on Health Care Services and recently served on the Committee on the Future of Nursing 2020-2030.  Prof. Sage is a member of the Healthcare System and Value Research (HSVR) study section for the Agency for Healthcare Research and Quality (AHRQ), an elected Fellow of the Hastings Center on bioethics, and a longtime editorial board member of the journal Health Affairs.  He has written over 200 articles and has authored or edited four books, including the Oxford Handbook of U.S. Health Law (2016).  He holds an undergraduate degree from Harvard College, medical and law degrees from Stanford University, and an honorary doctorate from Universite Paris Descartes.