January 11, 2011
Premier Safety Institute - Safety Share Newsletter

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Our patient just died from a medical error: What next?

Medical ErrorYou just received this report and the questions are flying around the hospital. How much does the family know? Who did it? What should we say? Would the patient have died anyway since he was very sick? Has anyone gone to the press? What should we do next? The new IHI white paper can help you.
 


"Respectful Management of Serious Clinical Adverse Events,"
the first of its kind white paper developed by the Institute for Healthcare Improvement (IHI) contains tools and resources to guide leaders in developing a clinical crisis management plan before they need it and a practical resource to guide their efforts in the absence of a plan.(1)
 

Every day these clinical adverse events occur within our healthcare system and cause physical and psychological harm to our patients, families, staff, the community and organizations. In the crisis that emerges, positively or negatively, the organization displays its understanding of its 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, family, staff and organization; and how actions immediately and over time bring empathy, support, resolution, learning and improvement.
 

The risk of not responding to adverse events quickly and effectively are huge, and include loss of trust, no learning or improvement, the sending of mixed messages about what is really important to an organization, increased likelihood for regulatory action or lawsuits, and challenges by the media.
 

Although this white paper focuses on serious clinical adverse events, the principles can be used to manage any adverse event, as well as other breaches, such as identity theft, behavioral issues, and other operating issues requiring respectful, effective crisis management.  
 

Leaders recognizing poor job in managing tragic events
According to lead author and IHI Senior Fellow Jim Conway, "Since releasing this report, with more than 5,000 people downloading  the file to date, there  have been a number of consistent themes among the respondents, including: 1) organizations that didn’t have a plan (most) wondered why they thought that was OK; 2) the lack of appreciation of how all the pieces – patient and family, staff, and organization – fit together; 3)  leaders reporting a significant lack of recognition of the needs of staff; 4) an opportunity for reflection on the poor job being done on managing these events." Conway also noted "A number of organizations are already using the resources to manage tragic events to guide a timely and balanced response and sharing content for further improvement by all."
 

Practical approaches and tools
The white paper is filled with practical approaches, detailed checklists, action plans and tools. A few of the tools include examples of phrases and words to use in communicating with patients, families and the community; engaging with the media; disclosing adverse events affecting multiple patients; and responding to serious events that happen in other organizations. 
 

Every healthcare leader should read and act on this white paper. They have the responsibility to ensure that in the aftermath of tragic events, everyone - patient and family, staff, organization, community - can say they were treated with respect. It is the same response we would want for them and those they love. Healthcare leaders owe their patients, family members, staff and the community nothing less. (2)


  1. Conway J, Federico F, Stewart K, Campbell MJ. Respectful management of serious clinical adverse events. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2010. 

    This IHI White paper is available on the IHI website.

    IHI has also built a website with extensive crisis management resources.

    American College of Healthcare Executives (ACHE) featured the IHI white paper in its Nov-Dec issue of Healthcare Executive in the article titled "Planning for a clinical crisis"

  2. Leape L, Berwick D, Clancy C, et al. Transforming healthcare: A safety imperative.  Quality and safety in health care. 2009; 18 (6):424-428.

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