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.

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.

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.

University of Missouri Health Care (MUHC) deployed an evidence-based emotional support structure for second victims based on research with recovering second victims known as the forYOU Team. It was designed to increase awareness of the second victim phenomenon, “normalize” the psychological and physical impacts, provide real-time surveillance for possible second victims within clinical settings, and render immediate peer-to-peer emotional support when a potential second victim is identified. This article describes the forYOU Team experience.

This is the website for the Washington Patient Safety Coalition’s (WPSC) Communication and Resolution Certification Program. When healthcare providers and organizations have utilized a CRP following an adverse event, they can apply for “CRP Certification.” A neutral group of patient safety experts and patient advocates has been convened to review responses to adverse events and certify whether the patient’s needs have been met, any individual or system-level inadequacies have been addressed, and learning has occurred. The certification process provides valuable feedback to healthcare organizations and demonstrates that they achieved all the essentials of a CRP.

The Washington Patient Safety Coalition is a program of the Foundation for Health Care Quality (The Foundation). The Foundation is a nonprofit organization dedicated to providing a trusted, independent, third party resource to all participants in the health care community – including patients, providers, payers, employers, government agencies, and public health professionals.

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.

The Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) started collaborating together to utilize its combined resources and knowledge to further  patient safety efforts and create safety systems in various healthcare settings.

This website offers resources and advice if you or a loved one has been harmed.

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.

Dr. Atul Gawande, general surgeon and part-time professor at Harvard University, analyzed the histories of various medical innovations, such as anesthesia and oral re-hydration therapy, and why they were successful or unsuccessful in swift diffusion. General obstacles included resistance from healthcare professionals, as well as weariness that the method was unsuccessful. However, general reasons why other methods were successful was because they combat the negative effects of germs and pain.

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 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.

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.

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.

This research article explores the use of a video-based communication assessment app to evaluate physician error disclosure skills. The study uses the generalizability theory to assess the reliability of crowdsourced laypeople and patient advocates in rating these skills, utilizing the Video-Based Communication Assessment app, which has not yet been evaluated for its effectiveness in medical harm scenarios. The researchers conducted a comparative analysis of crowdsourced laypeople and patient advocates as raters of physician error disclosure communication skills. The results of this study demonstrate that crowdsourced laypeople have the potential to provide reliable assessments of physician error disclosure skills. However, further research is necessary to explore the app’s effectiveness in different assessment scenarios.

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.

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.