Marx discusses uses a legal viewpoint to discuss how to be more tolerant of errors in the workplace, while also holding people accountable for their mistakes. He outlines four important behavior concepts, and how they can be applied to the healthcare system to decrease risk of adverse events and increase accountability: malpractice, understanding violations, ignorance, and mishaps.

The Medical Event Reporting System for Transfusion Medicine published the “Patient Safety and the ‘Just Culture’: A Primer for Health Care Executives” report, which consists of collected data and analyses on transfusion medicine practices and other related errors. This report also serves as a guide for healthcare administrators, human resource manages, and lawyers to understand current policies and how to successfully implement new investigating and reporting systems that acknowledge human errors and promote overall safety in the workplace.

Patients and family members identified the factors that contributed to their respective adverse incidents, such as not following safety measures and lack of communication. Participants stated that they were not involved in the analysis process of the adverse events, so they missed out on ways to become more involved in learning about adverse events and how they can be decreased in the healthcare setting. Thus, the authors of this article emphasize that healthcare systems should implement educational modules that not only help decrease the risk of adverse events, but also teach healthcare professionals, patients, and family members on how to be proactive in preventing them.

The purpose of this study was to examine the experiences of families and patients with medically adverse incidents, as well as to understand how different healthcare organizations respond to these events. Researchers found that, following adverse events, patient satisfaction was at its peak when communication was compassionate and included discussion of compensation. Satisfaction was also at its highest when physicians attentively listened to patients without interjecting during the conversation.

This article discusses the importance for healthcare organizations to understand the patient’s perspective after they received disclosure following an adverse medical event, because it could help them develop more effective communication methods. Researchers found that patients preferred it when healthcare systems disclosed adverse events to them. They also found that these systems should implement policies that promote disclosure between patients and physicians.

This article delves into the burnout epidemic plaguing physicians. The epidemic is caused by prolonged work hours, lack of resources, and demanding documentation. The burnout is also caused by emotionally stressing factors, such as those related to medically adverse incidents. To combat this epidemic, researchers of this article advocate for healthcare organizations to implement support systems that aid physicians’ well-being. In this study, the authors analyzed the effectiveness of a physician peer-support program in the Center for Professionalism and Peer Support at Brigham and Women’s Hospital. They found that this program used various techniques to promote physicians’ well-being, such as engaging in attentive listening and reflection to cope with stress in the workplace.

It’s part of health care providers’ professional culture to put their patients’ needs above their own. Before the COVID-19 crisis, health care providers had been experiencing a crisis of burnout which is now exacerbated by new challenges brought by the virus. This article provides several core principles as a way to move forward given the culture and challenges faced by health care providers.

By: Jo A. Shapiro, MD

Authors of this article emphasize how the “no blame” approach should be balanced with accountability when promoting patient safety in healthcare settings. However, this balance should be distributed among healthcare professionals, patients, and family members when effectively improving and promoting patient care and safety.

The purpose of this study was to identify certain communication behaviors linked with poor healthcare practice history in medical professionals. Researchers identified specific communication acts correlated with fewer malpractice allegations for physicians. Effective communication behaviors included utilizing humor and encouraging patients to express their opinions. Physicians can use these results to not only increase effective communication with their patients but to also decrease the risk of misbehavior and carelessness in the healthcare setting.

The authors of this article analyzed the importance of developing a support system for physicians so they can effectively cope with stress in the workplace, especially following an adverse medical event. Researchers found that peer support groups are one of the most effective support systems for physicians.

Improving how health care providers respond to medical injury requires an understanding of patients’ experiences. Although many injured patients strongly desire to be heard, research rarely involves them. Institutional review boards worry about harming participants by asking them to revisit traumatic events, and hospital staff worry about provoking lawsuits. Institutions’ reluctance to approve this type of research has slowed progress toward responses to injuries that are better able to meet patients’ needs. In 2015-2016, we were able to surmount these challenges and interview 92 injured patients and families in the USA and New Zealand. This article explores whether the ethical and medico-legal concerns are, in fact, well-founded. Consistent with research about trauma-research-related distress, our participants’ accounts indicate that the pervasive fears about retraumatization are unfounded. Our experience also suggests that because being heard is an important (but often unmet) need for injured patients, talking provides psychological benefits and may decrease rather than increase the impetus to sue. Our article makes recommendations to institutional review boards and researchers. The benefits to responsibly conducted research with injured patients outweigh the risks to participants and institutions.

Health care providers working on the front lines of the COVID-19 pandemic are threatened not only by exposure to the virus but also by pervasive and detrimental  effects on their mental health. Immediate actions need to be taken for a national strategy to safeguard the health and well-being of our clinicians. The article outlines 5 high-priority actions to protect the well-being of clinicians during and after COVID-19 crisis.

Written by: Victor J. Dzau, M.D., Darrell Kirch, M.D., and Thomas Nasca, M.D.

In this study, conference and process leaders were divided into three groups Morbidity and Mortality Conferences (MMCs), Educational Conferences, and Quality Assurance (QA) Meetings) to review adverse incidents and near misses, as well as to find ways to prevent them in the future as well as to promote patient safety. Researchers found that it is important to incorporate various approaches and clinical practices to effectively promote patient safety in the healthcare setting.

Communication breakdowns in cancer care are unfortunately common and represent a failure in patient-centered care. While multiple studies have elicited patients’ perspectives on these breakdowns, little is known about cancer care providers’ attitudes regarding the causes and potential solutions. The purpose of this article is to examine providers’ (1) perceptions of the nature and causes of communication breakdowns with patients in cancer care and (2) suggestions for managing and preventing breakdowns.

Previous studies suggest that psychologically safe workplaces foster a feeling of comfort among employees, allowing them to feel comfortable with taking risks, such as identifying mistakes in the workplace. In this study, researchers analyzed the levels of psychological safety in Veterans Health Administration (VHA) hospitals, and studied its relationship to employees’ comfort in disclosing medical mistakes. Researchers found that only a minority of workers were uncomfortable in admitting mistakes, and their discomfort was due to fear of retaliation.

Zerillo, Tardiff, Flood, Sokol-Hesner, and Weiss retrospectively coded 148 corrective actions from 67 safety events brought to a tertiary care academic medical center’s multidisciplinary hospital-level safety event review meeting from 2020 to 2021. They coded by category and strength, using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool. They found an inverse relationship between intervention strength and completion; the strongest interventions had the lowest rate of completion. Also, the majority of corrective actions were categorized as weak.

This article highlights the importance of developing systems for tracking the completion of corrective actions. Without tracking data on completion, organizations cannot know how well they are mitigating the risks to safety that their analyses have identified. By integrating action strength and completion status into corrective action follow-up, healthcare organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.

The National Patient Safety Foundation (NPSF) published this report on root cause analyses and actions (“RCA2”), which are programs aimed to reduce the risk of adverse medical events and instead increase effective measures to reduce them in the future. This report illustrates strategies that healthcare organizations can utilize when implementing RCA2 programs in the workplace. This report also details specific strategies that help healthcare organizations identify the faults and hazards in their systems that increase the risk of adverse medical outcomes, as well as how to take active and positive steps to prevent them from happening in the future.

Researchers concluded that an organizational culture characterized by anonymity, rewards and recognition for staff members making reports, grassroots involvement in the review and interpretation of data, and use of external sources of error data is critical for establishing a process truly capable of creating safety. This process for changing culture can be applied in any health care system desiring to improve the safety of the medication use process.

The authors of this article analyzed how medical mistakes and injuries are correlated with high healthcare costs and poor patient quality. To lower these rates, the authors emphasized the importance of implementing an incident reporting system in healthcare settings. The implementation of these systems involve changing the culture of the workplace, so it promotes learning, flexibility, and blamelessness.

The authors of this study analyzed the importance of healthcare professionals being transparent in medical malpractices with their patients in the Texas healthcare system. The authors found that medical mishap litigation helped significantly reduce suing and other damages. The authors also emphasized the importance for healthcare systems to work with attorneys, policy makers, and patients to help develop methods to be more transparent about medical mishaps and enforce proactive mediation.

This white paper introduces an overall approach and tools designed to support two processes: the proactive preparation of a plan for managing serious clinical adverse events, and the reactive emergency response of an organization that has no such plan.

Every day, clinical adverse events occur within our health care system, causing physical and psychological harm to one or more patients, their families, staff (including medical staff), the community, and the organization. In the crisis that often emerges, what differentiates organizations, positively or negatively, is their culture of safety, the role of the board of trustees and executive leadership, advanced planning for such an event, the balanced prioritization of the needs of the patient and family, staff, and organization, and how actions immediately and over time bring empathy, support, resolution, learning, and improvement. The risks of not responding to these adverse events in a timely and effective manner are significant, and include loss of trust, absence of healing, no learning and improvement, the sending of mixed messages about what is really important to the organization, increased likelihood of regulatory action or lawsuits, and challenges by the media.

The paper includes three tools for leaders (as appendices) — a Checklist, a Work Plan, and a Disclosure Culture Assessment Tool — and numerous resources to guide practice. The three tools are also included below as individual documents for ease of use.

The 2011 (second edition) update reflects a number of suggested improvements and clarifications, including new content on reimbursement and compensation as part of any discussion of disclosure and resolution, and disclosure of errors that have occurred at another institution, among other updates. Additional citations, resources, and examples from organizations mounting effective crisis responses are also included.

In this New England Journal of Medicine Perspective, Thomas H. Gallagher, M.D., and Allen Kachalia, M.D., J.D explore how in the modern ethical paradigm, any time harm occurs, clinicians and healthcare organizations are accountable for minimizing suffering and promoting learning, and why doing so is especially challenging when the harm was due to an error.

This commentary spotlights elements of ophthalmology practice that can influence error disclosure, particularly the prevalence of patients receiving care from optometrists outside the hospital environment with no central reporting mechanism.

Data from case studies support the fact that apologies from physicians to patients promote reconciliation and forgiveness. To promote a culture that supports apologizing and disclosure, 39 states, including Washington, D.C., are enacting apology policies to decrease the litigation problems surrounding medical malpractice. This article is delves into the implications surrounding the enactment of these laws. The article is divided into four parts. The first part of the article explains why states are passing apology laws and how they can help reduce lawsuits associated with medical malpractice. The second part presents data that supports the effectiveness of apology laws. The third part illustrates how apology laws affect various legal outcomes, especially the probability that medical providers will be presented with litigation fees. The fourth part of the article delves into the legal significance of their results. It is important to note that apology laws do not replace communication-and-resolution programs (CRPs), nor do they mitigate the existing data that these programs are effective in lowering the incidence rates of medical error claims.

Expectations for how radiologists should communicate with patients are in rapid evolution. Of all the communication challenges radiologists may encounter, disclosing harmful radiologic errors to patients looms as perhaps the most difficult. Calls are increasing for radiologists to communicate directly and transparently with patients after errors. This article explores the direct radiologist-to-patient disclosure of harmful radiologic errors. It further explores the profession’s aspirations toward enhanced patient care, professionalism, and visibility.

In the BMJ Quality & Safety Study (2009), researchers studied why clinicians are often considered “second victims” in the wake of medical errors. The researchers delved into how healthcare providers recover from the guilt and stress involved medical errors, and discuss the elements related to recovery and delineate from the second victim phenomenon. These factors include moving forward, receiving emotional support, and reestablishing a sense of integrity. Researchers recommended that it is important to for healthcare institutions to implement support systems that not only offer emotional aid but also decrease the likelihood of future adverse events.

The Covid-19 pandemic has amplified the immediate need for medical institutions to better support the emotional well-being of clinicians who are facing important emotional stressors, including grief from seeing so many patients die, fears of contracting the virus and infecting their family members, and anger over health care disparities and other systems failures. This article highlights the cultural and structural barriers that have caused existing emotional support programs to fail and describes key strategies that institutions can use to design peer-support programs that clinicians will embrace, such as reframing emotional stress, proactively engaging clinicians, making professional mental health services accessible, and holding institutional leadership accountable for clinician well-being.

Researchers acknowledged how a majority of adverse medical events involve patient harm. Patients and family are known as first victims. Researchers also acknowledged how healthcare professionals are also considered victims after an adverse event, due to the emotional and psychological trauma experienced after it. In other words, healthcare professionals are also known as second victims. In this study, researchers analyzed the various coping strategies that clinicians use in the wake of adverse events. These strategies include attending programs that offer emotional aid second victims, as well as taking accountability for the situation and learning from it.