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

Researchers reviewed patterns in healthcare policies and trends in five countries (the United States, the United Kingdom, New Zealand, Australia, and Canada) with histories of disclosing adverse incidents to patients. The researchers wanted to analyze the barriers that prevent healthcare providers and institutions from disclosing adverse events to their patients. They concluded that some barriers included difficulties with liability fees, patients’ beliefs on safety in the healthcare setting, and implementing policy changes on a large-scale. Effective ways to combat these challenges include carrying out a long-term program that involves educating patients and healthcare workers about safety.

Greater openness with patients about harmful errors is recommended. Many ethicists and professional organizations endorse disclosure of harmful errors to patients.The Joint Commission’s accreditation standards now require that patients be informed about unanticipated outcomes. In response, many hospitals are developing disclosure programs. Yet, recent studies suggest that disclosure of harmful medical errors to patients is the exception
rather than the rule. This article explores radiologists’ attitudes about disclosing errors to patients by using a survey with a vignette involving an error interpreting a patient’s mammogram, leading to a delayed cancer diagnosis.

Medical errors are unfortunately common. In the United States, Institute of Medicine proposed a set of guidelines for mitigating and disclosing errors. In order to implement these recommendations in pathology, it will require a better understanding of how errors occur in pathology, the relationship between pathologists and treating clinicians in reducing error, and pathologists’ experiences with and attitudes toward disclosure of medical error.This article aims to understand pathologists’ attitudes toward disclosing pathology error to treating clinicians and patients.

Despite the obvious need for open conversations with patients and their families following an adverse event, many organizations still lack the structure to support providers during this difficult time. In many cases, clinicians who have to disclose errors to patients and families fail due to lack of provider education and training, lack of confidence, fears of litigation and emotional distress.

The Ask-Tell-Ask Model focuses on successful disclosure coaching conversations. It includes:

1. Case Scenario
2. Key elements
3. Practical step-by-step strategies for disclosure coaching
4. Pedagogical model using the “Ask-Tell-Ask” approach
5. Organizational considerations for establishing a coaching program

This video focuses on principles and skills for effective disclosure conversations, especially around delayed cancer diagnosis, and includes a case example.

A short video of Dr. Shapiro speaking on disclosure of medical error to patients and families. This video is part of “Choosing Wisdom: The Path Through Adversity” documentary.

This article dissects the meaning of “disclosure-and-resolution” programs, which call health organizations to disclose medical errors to patients and families involved; apologize; and offer compensation when necessary. Health systems that used approach found decreased litigation fees. Researchers analyzed surveys in which individuals used “disclosure-and-resolution programs where appropriate. They found that increasing compensation allowances following an adverse event did not improve results, nor did it decrease the likelihood of patients and families filing lawsuits following an adverse event. Thus, it is important for healthcare systems to remember that “disclosure-and-resolution” programs may help promote effective and honest communication between patients and families, but it does not decrease associated legal costs or the possibility of a lawsuit.

Doctors and Litigation is a website produced by Dr. Gita Pensa, an Emergency Medicine physician at Brown was a defendant for 12 years, and regularly speaks on the topic at conferences and has a podcast “Doctors in Litigation: the ‘L’ word.”

Early Discussion & Resolution (EDR) Conversation Guidance from Oregon Patient Safety Commission offers general guidance that can serve as a foundation in initiating conversations and follow ups.

An adverse event can gravely affect both patients and their families and providers. Having a conversation between healthcare providers and patients about the incident can bring resolution and closure.

Goals of EDR from Oregon Patient Safety Commission:

1. Prevent an unfortunate situation from escalating
2. Restore the keystone of healthcare—the provider-patient relationship
3. Bring greater peace of mind to everyone
4. Learn from events to improve patient safety

Healthcare providers use root cause analysis to learn from malpractice and decrease the risk of adverse events. This method involves identifying the basic factors that cause performance variability. This model has three parts: 1) what occurred, 2) why did it occur, and 3) what strategies can be used to prevent the event from occurring in the future? This method is effective, because it helps healthcare providers identify the underlying causes of adverse events and take the necessary approaches to combat them.

Communication-and-resolution programs (CRPs) are implemented in hospitals to increase patient safety and effective communication between healthcare providers following patient injury. CRPs act as a guide for hospitals to disclose information to patients after medical injury, ways to efficiently investigate the incident, and how to take accountability for the event and offer compensation when appropriate. In this study, the authors analyzed the effectiveness of CRPs in reducing patient harm four Massachusetts health systems. The authors found that CRP implementation were correlated with decreased litigation fees, but they did not alter any other pertinent outcomes, such as reducing patient harm and increasing transparent communication.

Many organizations have struggled to implement CRP models smoothly. The study looks at factors that accounts for the success of two Massachusetts hospital system in implementing a CRP with high conformity to protocol without raising liability costs. Identified factors include: support of top institutional leaders, heavy investments in educating physicians about the programme, active cultivation of the relationship between hospital risk managers.

Abstract

Ernest Amory Codman MD (1869–1940) was a Boston surgeon who created a system in which he followed up with each of his patients years after hospitalization and recorded the end results of their care, including any errors in diagnoses and treatment. Dr. Codman then analyzed these errors and the correlation to patient health outcomes, and used them to make future improvements to not only increase patient safety but to excel as a healthcare provider.

Radiology’s leaders in peer review, patient-centered care, quality and safety, legal affairs, and institutional processes can help prepare radiologists to communicate openly with patients and families about errors by spearheading dialog within the profession regarding how best to implement this emerging practice standard.

Momentum has grown around turning the principle of being transparent with patients about harmful errors into practice. Most radiologists remain profoundly uncomfortable with the prospect of talking with patients about errors. This article describes recent developments driving widespread disclosure and apology efforts in the United States and looks at encouraging radiologists to prepare to discuss errors directly with patients.

The video includes three scenarios to demonstrate how different approaches to disclosure can have an effect on the course of communication with a patient’s loved one.

Disclosure Scenarios:

1. Disclosure with No Apology
2. Disclosure with Apology of Sympathy
3. Disclosure with Apology or Responsibility

Five doctors talk about their experiences surviving a medical malpractice lawsuit.

This guide for Getting Started with a CRP Policy or Commitment Statement outlines key elements and suggestions for developing an institutional CRP policy or commitment statement. It was developed by members of CAI’s Policy Committee in partnership with patient and family advocates.

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.

Two victims are involved in adverse incidents within health care. The first victim is the patient and family and the second is the health care provider. Researchers of this study focused on the effects of adverse events on healthcare professionals. They found that it is necessary to develop and implement support systems that can utilized by both patients, families, and healthcare providers when dealing with the effects of adverse incidents.

The object of this report is 1) to describe how hospitals use incident reporting systems and incident reports, 2) to determine the extent to which hospital incident reporting systems capture patient harm that occurs within hospitals, and 3) to determine the extent to which accrediters review incident reporting systems when assessing hospital compliance with Federal requirements to track instances of patient harm.

Communication-and-resolution programs (CRPs) in health care organizations seek to identify medical injuries promptly; ensure that they are disclosed to patients compassionately; pursue timely resolution through patient engagement, explanation, and, where appropriate, apology and compensation; and use lessons learned to improve patient safety. To make these programs more successful, legal entities should support them. State and federal policy makers should try to allay potential defendants’ fears of litigation, facilitate patient participation, and address the economic concerns of health care providers.

The existing structures and processes that together form an organization’s operating system need an additional element to address the challenges produced by mounting complexity and rapid change. The solution is a second operating system, devoted to the design and implementation of strategy, that uses an agile, network-like structure and a very different set of processes. The new operating system continually assesses the business, the industry, and the organization, and reacts with greater agility, speed, and creativity than the existing one. It complements rather than overburdens the traditional hierarchy, thus freeing the latter to do what it’s optimized to do. It actually makes enterprises easier to run and accelerates strategic change. This is not an “either or” idea. It’s “both and.” I’m proposing two systems that operate in concert.

The Joint Commission Journal on Quality and Patient Safety (2012) created a toolkit to help health care organizations implement support programs for clinicians suffering from the emotional impact of errors and adverse events. Based on the best available evidence related to the second victim experience, the toolkit consists of 10 modules, each with a series of specific action steps, references, and exemplars.

The human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error management. Understanding these differences has important practical implications for coping with the ever-present risk of mishaps in clinical practice.

The Agency for Healthcare Research and Quality (AHRQ) published the Communication and Optimal Resolution toolkit, which is a guide for the implementation of communication-and-resolution programs (CRPs). These are holistic and systematic methods for preventing and responding to adverse medical events involving patients. The toolkit also guides on how to promote sincere communication between patients, families and the healthcare team; appropriate financial compensation; and efficient ways to decrease future adverse medical events. The authors describe their personal experiences with applying CRPs in their medical practices in more than 200 hospitals. From their experiences, the authors describe the obstacles that prevented the success of CRP implementation, as well as how they overcame them.

The response to adverse events can lack patient-centered-ness, perhaps because the involved institutions and other stakeholders misunderstand what patients and families go through after care breakdowns. A PFAC-designed simulation can help stakeholders understand patient and family experiences following adverse events and potentially improve their response to these events.