Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different sources and institutions. Incident reports collected from IRS, patient complaints and retrospective chart review in an academic acute care hospital were classified using the ICPS. In conclusion, IRS do not capture all incidents in hospitals and should be combined with complementary information about diagnostic error and delayed treatment from patient complaints and retrospective chart review. Since incidents that are not recorded in IRS do not lead to remedial and preventive action in response to IRS reports, healthcare centres that have access to different incident detection methods should harness information from all sources to improve patient safety.

This article discusses the prevalence of disruptive behavior in the healthcare setting, which is defined as any act that influences a group’s intended outcome. Disruptive behavior often takes the form of angry outbursts and passive aggressive actions, especially in extremely stressful environments, such as emergency rooms. This behavior is often detrimental to the culture of safety and quality healthcare, as well as increases the risk of lawsuits. To combat disruptive behavior, five principles are are offered as guides to promoting professionalism and professional accountability in support of quality team-oriented care, patient safety and, if necessary, legal defense if disruptive colleagues challenge disciplinary interventions. 

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.

The Agency for Healthcare Research and Quality (AHQR) developed the CANDOR (Communication and Optimal Resolution) Event Checklist, which is a guide to be used by the CANDOR team after an adverse event occurred in the healthcare setting. The checklist includes effective ways of reporting, assessing, investigating, and analyzing the adverse event to decrease the likelihood of future incidents occurring, as well as improving the overall quality of patient care and safety.

The CANDOR Event Review Report Template is a guide used to analyze and investigate barriers that contributed to an adverse health event. Barriers include poor communication behaviors, unsafe physical environment, inadequate care, and equipment device failure. This template also includes a guide to assess who was responsible for the adverse event, and ways to develop solutions for it so it.

“Annie’s Story” is an example of how healthcare organizations seeking high reliability embrace a just culture in all they do. This includes a system’s approach to analyzing near misses and harm events—looking to analyze events without the knee-jerk blame and shame approach of old. This video specifically focused on Nurse Andrea’s personal experience with an adverse health event with a patient who underwent a hypoglycemic emergency due to a misreading of a glucometer. The video then details the steps she and the hospital took to prevent future adverse health events, as well as other ways to increase overall patient safety and quality.

This article explains the challenge of balancing accountability and a “no blame” model in healthcare systems when promoting patient safety. Accountability is defined as taking responsibility for one’s actions. In this article, it is taking responsibility for malpractice that increases patient harm. the “no blame” model is defined as not accusing a single entity for any healthcare misconduct. It is important for healthcare systems to embody both taking responsibility for healthcare malpractices as well as the “no blame” model to effectively promote patient safety and quality and reduce adverse health events.

Webinar Date: February, 2021

Overview: COVID-19 has fundamentally altered our care processes and standards.  Care is being delayed, visits are happening by telemedicine, there are changes in how staff are deployed and interact with patients, and everyone is exhausted and emotionally depleted. These all make potential for patient harm events higher.  COVID-19 is also adding stress to already tightening medical professional liability insurance market. While it may be tempting to abandon ship when it comes to implementing CRP during COVID-19 times, CRPs are more important now than ever.  Fundamental principles of the CRP model-supporting patients, families, and clinicians after harm with open communication, empathy, learning, and accountability – are critical elements of how we respond to COVID-related harm events.  This webinar examines two cases of COVID-associated adverse events to help lead a discussion on the challenging aspects in implementing CRPs during this time.

Presenters: Michelle Mello, JD, PhD, and Thomas H. Gallagher, MD

Commentary by: Jeffrey Catalano, JD, Marcia Rhodes, Jonathan Steward, JD, MS, RN-BC, CEN, CPHRM

Learning Objectives: 

• Examine potential communication and legal issues associated with COVID-related harm events
• Describe how CRPs can be used as a strategy to address these COVID-related adverse events
• Learn about CRP resources to help address COVID-related challenges

Join Dr. Daniel B. Kramer, MD, MPH, at Harvard Medical School

Learning Objectives:

1. To understand potential clinical manifestations of medical device malfunction

2. To review opportunities to communicate known and emerging risks related to medical device use with patients

3. To explore financial and ethical responsibilities of different stakeholders when patients experience harm from medical device malfunction

Webinar Date: November 17, 2022

Presenters: Lauge Sokol-Hessner, MD, CPPS

Lauge Sokol-Hessner, MD, CPPS is a hospitalist, Clinical Associate Professor of Medicine at the University of Washington, QI Mentor at the UW Medicine Center for Scholarship in Patient Care Quality and Safety, speaker and consultant for the Institute for Healthcare Improvement, and a guest speaker for the Harvard Medical School Masters in Healthcare Quality and Safety (HMS MHQS). He has experience in operational quality & safety, developing leaders in quality & safety, teaching communication skills, coaching health care organizations to implement highly-reliable CRP programs, and he champions patient and family engagement, ethics, humanism, equity, and respect in health care. He completed medical school and residency at the University of Pennsylvania.

Webinar Date: October 22, 2020

Dr. Urmimala Sarkar discusses healthcare disparities and specific challenges to adverse event communication among diverse populations within the CANDOR process.

Presenter: Urmimala Sarkar MD, MPH, Professor of Medicine at UCSF in the Division of General Internal Medicine, Associate Director of the UCSF Center for Vulnerable Populations, and primary care physician at Zuckerberg San Francisco General Hospital’s Richard H. Fine People’s Clinic

Objectives: 

• Examine disparities in healthcare and which populations are more likely to experience lower quality healthcare and adverse events
• Delineate how low-income, limited literacy, racially/ethnically diverse populations may experience the response to adverse events differently
• Characterize specific challenges for adverse event communication among diverse populations
• Identify best practices from lived experience among risk management professionals for communicating across differences in the aftermath of adverse events

Webinar Date: September 17, 2020

Dr. Gordon Schiff talks about diagnostic error and how efforts to reduce diagnostic error align with the principles of communication and resolution programs.

Presenter: Dr. Gordon Schiff (Brigham and Women’s Center for Patient Safety Research and Practice, Harvard Medical School)

Objectives: 

1. Describe the frequency/epidemiology of diagnostic errors based on published studies and surveys.
2. Define diagnosis errors, and using a Venn diagram model differentiate diagnostic process errors, misdiagnosis, and adverse outcomes.
3. List 3 approaches to minimizing and preventing diagnostic errors.
4. Explain ways that missed/under diagnosis and overdiagnosis are related rather than just opposites
5. Describe overlapping and synergistic domains between the diagnostic error/improvement movement andCommunication and Resolution Program (CRP) efforts.

Mitigating the Toll of Medical Errors on Clinicians by Jo Shapiro, MD, FACS

Webinar Date: October 31, 2019

As a clinician, being involved in adverse events can have devastating emotional consequences. How we react to these events – as individuals, colleagues and organizations – has a major effect on our organizational culture of psychological safety, provider wellbeing, disclosure and reporting, and patient safety.  Dr. Shapiro’s presentation will detail these effects and address the unique role that frontline physicians can play in supporting one another after adverse events. She will describe the peer support program developed at Brigham and Women’s Hospital and adopted by dozens of healthcare organizations. She will describe the building blocks of a creating and sustaining a peer support program, including providing the participants with the rationale to bring to leadership in advocating for peer support program resources.

Learning Objectives:

1. Identify the emotional impact of adverse events on clinicians
2. Recognize the impact this has on a culture of psychological safety, provider wellbeing, disclosure and reporting, and patient safety.
3. Provide a rationale to leadership for developing a peer support program
4. Delineate the foundational aspects of a peer support program

Webinar presented by Dr. Tom Gallagher on Thursday, June 6, 2019

Large-scale adverse events, situations in which a breakdown in care has affected multiple (sometimes thousands) of patients, pose significant challenges for institutions related to responding in ways that inform potentially affected patients without unduly alarming them and managing the follow-up. This webinar will highlight lessons learned from the field around responding effectively to adverse events, as well as key unanswered questions.

Learning objectives:

1. Describe the diversity of large-scale adverse events, and how responding to these events differs from managing adverse events that affect individual patients
2. List the key elements of an effective response to a large-scale adverse events and the tools that are currently available to assist with this process
3. Critique an actual large-scale adverse event patient notification letter and press release, and articulate opportunities for improvement in these documents.

WEBINAR DATE: July 16, 2020

This webinar outlines the concerns and questions about the collision between the judicial system and its pathway to addressing medical error and CRP programs.

PRESENTERS: Cindy Jacobs, RN, JD

OBJECTIVES:

1. Describe the basics of how the tort system operates in a medical error/adverse outcome situations
2. Describe the basics and how, when, and why CRP “apology laws,” “mandatory disclosure” laws/requirements, and healthcare licensing systems intersect and/or collide with the tort system
3. Identify key points to assist healthcare professionals in navigating intersections and collisions

From the Canadian Patient Safety Institute

Prevent Patient Safety Incidents and Minimize Harm When They Do Occur
When a patient’s safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. CPSI provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process.

Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.

The “Second Victim Rapid Response Team” was a system created to provide psychological, social, and emotional support for healthcare providers who are known”second victims” in the wake of any adverse health outcome or compromise in patient safety.

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.

The Patient Notification Toolkit was developed to address injection and contagion control malpractice, which occurs in various healthcare settings, such hospitals, and assisted living facilities. These incidents compromise the patients’ health by increasing their risk of infection. When healthcare malpractices or resulting infections are exposed, patients are notified through a detailed process carried out by state and local health departments or healthcare facilities.

In communication-and-resolution programs (CRPs), health systems and liability insurers encourage the disclosure of unanticipated care outcomes to affected patients and proactively seek resolutions, including offering an apology, an explanation, and, where appropriate, reimbursement or compensation. Anecdotal reports from the University of Michigan Health System and other early adopters of CRPs suggest that these programs can substantially reduce liability costs and improve patient safety. In this study, CRP participants were interviewed. They identified several factors that contributed to their programs’ success, including the presence of a strong institutional champion and investing in building and marketing the program to skeptical clinicians.

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.

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

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.

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.

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.