Discerning complicated approach of ethics and professionalism in medicine can be difficult. It’s similarly challenging when clinicians have to navigate through clinical or relational situation and develop an understanding of ethical, legal and more issues.

The Case Files consist of carefully crafted cases designed to stimulate proper approach and decision-making process. Case 18 focuses on transparent and compassionate disclosure and apology, and recognizing emotional challenged clinicians may face after an adverse event.

Crisis Standards of Care (CSC) was developed in 2009 by the Institute of Medicine in response to consecutive catastrophic disasters happening around the world. The report provides a framework for a systems approach to the development and implementation of CSC plan that should apply in disaster or crisis situations. It was designed to help state and local public health officials and health-sector agencies and institutions operationalize CSC.

Institute of Medicine; Board on Health Sciences Policy; Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations; Dan Hanfling, Bruce M. Altevogt, Kristin Viswanathan, and Lawrence O. Gostin, Editors

The Handbook of Human Factors and Ergonomics in Health Care and Patient Safety offers a detailed overview of ergonomics and and human factors, theories, methods, and models that are pertinent to patient care and safety. Specific topics included in this book include telemedicine, infection prevention, and anesthesia safety.

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.

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.

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.

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.

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.

This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.