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.

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.

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.

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.

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: 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.

Webinar Date: July 21, 2022

Presenters: Kyle Sweet, JD

Kyle Sweet is an Oklahoma-based defense lawyer represents healthcare providers in catastrophic injury cases around the United States. Kyle teaches in medical schools, dental schools and teaches seminars regularly to healthcare providers on how to avoid litigation by improving quality of care through more effective communication. Kyle is proud to serve on the CAI and looks forward to helping make Communication Resolution Programs the industry standard.

Webinar Date: April 15, 2021

Presenters:

• Suz Schrandt, JD,  Senior Patient Engagement Advisor, Society to Improve Diagnosis in Medicine; Founder, CEO, & Chief Patient Advocate at ExPPect
• Eric J. Thomas, MD, MPH Associate Dean for Healthcare Quality, McGovern Medical School, University of Texas Health Science Center at Houston; Board President, Collaborative for Accountability and Improvement

Objectives:

• Understand the individual and system factors that can cause diagnostic errors
• Explore the benefits of a CRP response following a diagnostic error
• Examine the consequences of a poor response to a diagnostic error
• Understand the importance of engaging, listening, and learning from patients and families following diagnostic errors

Webinar Date: January 18, 2024

Presenter: Bruce Lambert, PhD, professor in the Department of Communication Studies and the Department of Medical Social Sciences at Northwestern University

Learning Objectives: 

• Describe the role and capabilities of AI in empathetic interactions in healthcare: Participants will learn about the current state of AI in replicating empathetic responses, including the mechanisms through which AI mimics empathy and its effectiveness compared to human empathy.
• Weigh competing ethical implications of AI-generated empathy in healthcare: Attendees will gain insights into the ethical considerations involved in using AI for empathetic purposes in healthcare contexts, focusing on issues of transparency, authenticity, and the balance between practical benefits and ethical responsibilities.
• Critically evaluate the impact and future directions of AI in empathy: The audience will be encouraged to critically evaluate the potential impacts of AI on the future of empathetic interactions in healthcare and other professional settings, considering both the opportunities and challenges presented by AI integration.

Communication-and-resolution programs (CRPs) aim to increase disclosure, learning, and responsibility following adverse medical incidents. The authors of this article identify five obstacles that prevent CRPs from being successful: 1) public policy, 2) compensation for patients following medical errors, 3) application fidelity, 4) evidence of CRPs increasing patient safety, and 5) alignment of CRP methods with patient needs. To increase the success of CRPs, it is recommended that they should be coupled with CRP quality programs. Overall, health institutions are advised to implement these programs into their systems to promote transparency and patient and family engagement.

This article explains how healthcare providers and insurers were skeptical of the Agency for Healthcare Research and Quality’s Communication (AHQR) Communication and Optimal Resolution (CANDOR) toolkit, which is a guide for healthcare providers to use if there was patient injury. Healthcare providers and insurers are weary of the CANDOR toolkit, since it does not quickly fix litigation scandals. This toolkit also does not effectively identify patient safety risks. However, the CANDOR toolkit is an effective step for healthcare providers to take in being honest and transparent with their patients about any malpractice or increased risk of injury.

Communication and Resolution Programs (CRPs) investigate and and communicate about events not caused by substandard care. CRPs were quite successful in handling such events, but less consistent in offering compensation in cases involving substandard care.

The Journal of Patient Safety and Risk Management published study of an “open” hospital system shows that a Collaboration Communication-and-Resolution Program (CRP) cut lawsuits by two-thirds and reduced legal expenses and the time needed to resolve claims. Due to this program’s success, physicians are encouraged to integrate CRPs into their health practices to increase overall patient health quality and safety.

Among patients with chest pain, the implementation of a comprehensive communication-and-resolution program was associated with substantially reduced growth rates in the use of diagnostic testing and imaging services. Further research is needed to establish to what extent these changes were attributable to the program and clinically appropriate.

The Communication and Resolution Program (CRP) Certification program is a promising example of collaboration among institutions, insurers, and regulators to promote patient‐centered accountability and learning following adverse events in the healthcare setting. These programs are successful, because they promote transparency among patients after an adverse health incident, and increase overall health quality.