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.

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.

39 states have apology laws, with over a third applying to healthcare or other contexts. After over a decade of experience with apology laws, the authors explore whether apology laws reduce malpractice liability risk and why, and whether there is a reason to have them.

Medical errors are associated with significant emotional, financial, physical and sociobehavioural impacts including reduced trust and willingness to seek healthcare. These impacts can last for years. The study sought to understand whether greater open communication is associated with reduced emotional impacts and decreased avoidance of doctors/facilities involved in the error.

Background: The emotional impact of medical errors on patients may be long-lasting. Factors associated with prolonged emotional impacts are poorly understood.

Methods: The authors conducted a subanalysis of a 2017 survey (response rate 36.8% [2,536/6,891]) of US adults to assess emotional impact of medical error. Patients reporting a medical error were included if the error occurred ≥ 1 year prior. Duration of emotional impact was categorized into no/short-term impact (impact lasting < 1 month), prolonged impact (> 1 month), and especially prolonged impact (> 1 year). Based on their reported experience with communication about the error, patients’ experience was categorized as consistent with national disclosure guidelines, contrary to guidelines, mixed, or neither. Multinomial regression was used to examine associations between patient factors, event characteristics, and organizational communication with prolonged emotional impact (> 1 month, > 1 year).

Results: Of all survey respondents, 17.8% (451/2,536) reported an error occurring ≥ 1 year prior. Of these, 51.2% (231/451) reported prolonged/especially prolonged emotional impact (30.8% prolonged, 20.4% especially prolonged). Factors associated with prolonged emotional impact included female gender (adjusted odds ratio 2.1 [95% confidence interval 1.5–2.9]); low socioeconomic status (SES; 1.7 [1.1–2.7]); physical impact (7.3 [4.3–12.3]); no organizational disclosure and no patient/family error reporting (1.5 [1.03–2.3]); communication contrary to guidelines (4.0 [2.1–7.5]); and mixed communication (2.2 [1.3–3.7]). The same factors were significantly associated with especially prolonged emotional impact (female, 1.7 [1.2–2.5]; low SES, 2.2 [1.3–3.6]; physical impact, 6.8 [3.8–12.5]; no disclosure/reporting, 1.9 [1.2–3.2]; communication contrary to guidelines, 4.6 [2.2–9.4]; mixed communication, 2.1 [1.1–3.9]).

Conclusion: Prolonged emotional impact affected more than half of Americans self-reporting a medical error. Organizational failure to communicate according to disclosure guidelines after patient-perceived errors may exacerbate harm, particularly for patients at risk of health care disparities.

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.

The Journal of Patient Safety and Risk Management published study of an “open” hospital system shows that a Collaboration Communication-and-Resolution Program (CRP) cut lawsuits by two-thirds and reduced legal expenses and the time needed to resolve claims. Due to this program’s success, physicians are encouraged to integrate CRPs into their health practices to increase overall patient health quality and safety.

This study analyzed if a communication-and-resolution program (CRP) was effective in lowering adverse events among patients with chest pain, as well as lowering medical costs. The study concluded that the implementation of the CRP was efficient, since it helped increase the number of chest pain diagnoses as well as significantly reduced associated health costs.

Loren et al. conducted a qualitative thematic analysis following in-depth interviews with parents who believed they had experienced an adverse birth-related neonatal outcome and focus groups with healthcare providers who have communicated with parents about adverse newborn birth events. The analysis revealed six key themes characterizing the unique aspects of the birth experience and associated communication challenges:

1. High expectations for positive outcome
2. Powerful emotions
3. Rapid change and progression
4. Family involvement
5. Multiple patients and providers
6. Litigious environment

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

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

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.

Publish Date: January 28, 2020

A systematic review of 37 studies of malpractice deterrence  published between January 1, 1990, and November 25, 2019 was conducted to examine the association between malpractice liability risk and health care quality and safety. This review found that most studies suggest that higher risk of malpractice liability is not significantly associated with improved health care quality. The findings also suggested that greater tort liability was not associated with the improvement of quality of care.

Publish Date: January 28, 2020

This issue presents a thorough and rigorous analysis of recent research and draws findings from 37 studies.  It conclude that increased liability exposure, such as numbers of malpractice claims or changes to state malpractice laws, was not associated with improvement in the quality of patient care.

Communication-and-resolution programs (CRPs) help healthcare providers and insurers effectively communication with patients when  medically adverse event occurs, as well as offer the necessary steps to take to give compensation. Researchers examined the effectiveness of CRP implementation in two Massachusetts hospitals. They concluded that, when the hospitals followed the CRP protocols, there were no drastic increases in liability fees associated with adverse health outcomes. Thus, CRPs helped these hospitals proactively handle adverse incidents and any related litigation fees.

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.

The purpose of this study was to determine whether a communication and optimal resolution (CANDOR) program was effective in reducing the number of health liability processes and associated adverse outcomes. Researchers found that this program helped significantly increase the number of incident reports received, as well as decreased the litigation, settlement, and self-insurance fees associated with medical malpractices and adverse events.

Patient and family emotional harm after medical errors may be profound. At an Agency for Healthcare Research and Quality (AHRQ) conference to establish a research agenda on this topic, the authors used visual images as a gateway to personal reflections among diverse stakeholders. Themes identified included chaos and turmoil, profound isolation, organizational denial, moral injury and betrayal, negative effects on families and communities, importance of relational skills, and healing effects of human connection. The exercise invited storytelling, enabled psychological safety, and fostered further collaborative discussion. The authors discuss implications for quality/safety, educational innovation, and qualitative research.

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.

Although open communication with patients is the established best practice after a medical error, healthcare providers’ conversations with each other in these circumstances are less studied. The authors identified and compared what providers identified as the most important thing to say to their peer and to the patient after a medical error. The found that providers approach conversations about medical errors with a peer differently than with patients and may benefit from additional communication training or support.