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.

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.

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.

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.

Medical errors not only negatively affect patients involved but also healthcare workers, to the point that they have been dubbed “second victim” due to the psychological and emotional stress caused from the event. In this study, researchers examined how healthcare workers recover from medical errors. Recovery methods include receiving emotional first aid, re-developing a sense of integrity, and learning to cope with the negative event.

This article discusses the importance of implementing a holistic approach to address both processes and culture in providing safe and exceptional care to patients. This article also includes a road map for healthcare providers, so they can efficiently assess the strengths and weakness of their current care system, so they can organized and intentional in their work, allowing them to improve overall patient care and safety in any clinical setting.

Dr. Shapiro talks about the importance of having disclosure coaching program and fundamental principles of disclosure coaching. For more videos related to Disclosure and Apology, view the video gallery.

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.

This article focuses on the negative impacts adverse events have on healthcare professionals. Specifically, they feel a sense of inadequacy, shame, and personal grief. As a result, healthcare professionals are dubbed “second victims” of these incidents. The article also delves into obstacles that prevent healthcare professionals from seeking assistance. These obstacles include not wanting to be perceived as vulnerable or weak in front of their coworkers. To assist second victims and their recovery and combat the stigma associated with seeking help, health institutions are encouraged to develop holistic support systems.

This thesis paper delves into the importance of classifying healthcare conflicts into relationship-based groups  to appropriately address the dynamics, goals, and interventions associated with the conflict. These dynamics include ways of improving communication and rapports, as well as efficiently saving money.

The Medstar’s Patient Safety and Quality Program included this video in their patient safety and care program. This video illustrates the story of Michael Skolnik, who lost his life due to medical malpractice. The error involved the surgeon not being completely transparent with the patient or his family about the surgical procedure. This video emphasizes the importance of shared decision making between patients, families, and physicians to avoid future adverse medical outcomes, especially ones in which lives are lost.

The objective of this study was to determine whether a communication-and-resolution program (CRP) to adverse patient events is correlated with changed in medical litigation actions and outcomes.  Researchers found that the implementation of a communication and optimal resolution (CANDOR) program was most successful. These programs consist of methods for effectively identifying an event, investigation, resolution, and care for healthcare providers. The CANDOR program was correlated with long-lasting fiscal and clinical improvements. It also helped increase incident report rates, as well as decrease the number of litigation and malpractice claims and fees.

Patient and family emotional harm after medical errors may be profound. At an Agency for Healthcare Research and Quality (AHRQ) conference to establish a research agenda on this topic, the authors used visual images as a gateway to personal reflections among diverse stakeholders. Themes identified included chaos and turmoil, profound isolation, organizational denial, moral injury and betrayal, negative effects on families and communities, importance of relational skills, and healing effects of human connection. The exercise invited storytelling, enabled psychological safety, and fostered further collaborative discussion. The authors discuss implications for quality/safety, educational innovation, and qualitative research.

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.

This article discusses the “end result idea,” a concept that describes that physicians should follow up with their patients after treatment to evaluate their results as well as to make these assessments public. The “end result idea” promotes the fact that physicians should be transparent with their patients as well as the public in addressing health outcomes. By being transparent, physicians and healthcare institutions can promote patient safety, healthcare professional learning, and overall healthcare quality.

University of Missouri’s forYOU Team is an organization that supports caregivers in the aftermath of traumatic medical incidents or during the stress of their job. The institution offers multiple resources on identifying symptoms of distress as well as how to support caregivers.

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.

The Virtual Lecture Hall offers a two-hour course called Human Side of Medical Errors, which will effectively teach participants how to make ethical decisions when providing medical services to colleagues or loved ones, as well as how to constructively respond to a patient’s emotional reaction after they were involved an adverse incident.

The Foundation for Health Care Quality is a Seattle-based nonprofit foundation that offers third party sources to everyone involved in healthcare, including physicians, patients, government organizations, and payers. The institution offers various resources to promote healthcare quality and patient care, such as assessment and communication-and-resolution (CPP) programs.

Although open communication with patients is the established best practice after a medical error, healthcare providers’ conversations with each other in these circumstances are less studied. The authors identified and compared what providers identified as the most important thing to say to their peer and to the patient after a medical error. The found that providers approach conversations about medical errors with a peer differently than with patients and may benefit from additional communication training or support.

The objective of this study is to analyze incident reports from hospital patients to identify adverse medical incidents and near-miss mishaps in their care. Researchers found that most of the adverse events involving patients are not identified. Thus, it is important for hospital systems to partner with patients to efficiently and quickly identify adverse medical events and errors to promote overall healthcare quality and patient safety.

Michelle Mello, the Director of the Program in Law and Public Health at the Harvard School of Public Health, analyzed the effectiveness of communication-and-resolution programs (CRPs) in this article. She found that these models are efficient at addressing healthcare liability issues revolving around adverse medical outcomes. These programs offer a guide for healthcare professionals on how to disclose medical errors to their patients, while also developing ways to prevent future adverse events.

When a patient is unintentionally harmed during medical treatment, how should organizations respond?

Not that long ago, steps like these were unthinkable and, from a risk manager’s perspective, totally unwise. Today these practices are at the core of what are called communication and resolution programs (or CRPs), and their architects say there’s been a significant uptick in US health systems using them. Our guests are two leading experts on CRPs, Tom Gallagher and Allen Kachalia. They and a team of researchers have been teasing out the reasons why so many health care leaders are committed to the principles of CRPs, but hesitant to deploy the practices.

If you’ve been wondering what’s been going on with CRPs and new ways forward, this WIHI is for you.

This article explores how physicians gain wisdom following an adverse medical event. Methods included discusses the incident with colleagues, forgiveness, accepting imperfection in the medical profession, and admitting the mistake and apologizing. These methods not only help physicians learn and cope with medically adverse events, but also help them develop a positive outlook.

“We Signed Up for This!” — Student and Trainee Responses to the Covid-19 Pandemic by Thomas H. Gallagher, M.D., and Anneliese M. Schleyer, M.D., M.H.A.

Despite the risk and challenges, students and trainees showed their unrelenting desire and commitment to care for the sick. Residents helped cover extra shifts, students prepared home care kits for Covid-19 patients, and even provided child care for health care workers. The unprecedented public health crisis caused students and trainees to experienced considerable loss.

A short anonymous survey was conducted to learn how COVID-19 is affecting students and trainees. Responses from University of Washington medical students, residents and fellow reveal a mixture of safety, quality of care and practical concerns among the participants. The article also includes how leaders in medical education can provide support and convert this crisis to a valuable learning experience for all the students and trainees.