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

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
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
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

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

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