IHI periodically receives urgent requests from organizations seeking help in the aftermath of a serious organizational event, most often a significant medical error. In responding to such requests, we draw on learning and examples assembled from many courageous organizations over the last 15 years who have respectfully and effectively managed these crises.

In addition to providing direct support to organizations, IHI sought to formalize the collective counsel we are giving. In developing this content area, IHI has assembled two sets of resources:

• A slide set (and future paper) distillation of our learning from many organizations, as well as from the crises management literature and experts; and 
• A collection of materials from organizations describing their journey and learning after tragic events (see the resources below).

Our goals are to:

• Encourage and help organizations assemble crisis management plans BEFORE they need to utilize them;
• Integrate them in their culture of quality and safety, with a particular focus on patient- and family-centered care and fair and just practice; and
• Offer a concise, immediate resource to inform efforts in the absence of an organizational crisis plan and/or culture of quality and safety.

Share Your Learning and Questions

We encourage those of you using this material to share your learning and let us know how it can be improved. Please tell us the challenges you are facing, the journeys you have taken, the questions and barriers that exist, and if there is a need you have that the content doesn’t address.

Go to the Discussion Group

Download the documents or visit the web resources below for more information.

Bibliographies

• Effective Crisis Management Bibliography
• Disclosure of Adverse Events to Patients Annotated Bibliography
• Communicating After an Adverse Event: Selected Bibliography and Resources

WIHI Broadcasts

The WIHI "talk show" program from IHI features 60-minute broadcasts on cutting-edge health care improvement topics.

• Message to Managers: Crises Happen. Plan Ahead! (March 4, 2010): Jim Conway, Timothy McDonald, Richard Boothman

Listen to a recording of the program

Resources mentioned on the program

• Adverse Events and Their Aftermath: SOS from Clinicians (February 4, 2010): Albert Wu, Linda Kenney, Susan D. Scott

Listen to a recording of the program

Resources mentioned on the program

Other Resources

Respectful, Effective Crisis Management

A presentation by IHI Senior Vice President Jim Conway that distills learning about crisis management from other organizations' experiences, the literature, and experts in this field.  

IHI Disclosure Toolkit and Disclosure Culture Assessment Tool

The toolkit and self-assessment tool help health care organizations develop a culture that supports respect and effective communication with patient and families around adverse events.

Running a Hospital Blog Post: Wrong-Sided Surgery

A blog post by Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, about a wrong-sided surgery event.

Leadership Practices to Advance Patient Safety

A preventable death due to a medical error strengthens Catholic Healthcare Partners' commitment to building a culture of safety.

The Demands of Leadership During a Safety Crisis

A presentation describing a clinical adverse event at Children's Hospital in Boston and the resulting "call to action" to strengthen the hospital's safety processes. 

When Lightning Strikes Twice: Sexual Abuse by Employees in Children's Hospitals

Communicating with the Media: The DFCI Experience

This presentation provides an overview of the high-profile Betsy Lehman overdose incident at Dana-Farber Cancer Institute (DFCI)in Boston, and how the organization handled communications about the event.

HRET Informing Practice Study Series: Patient Safety and Team Training

A case study of how Duke University Health System established an infrastructure to identify and mitigate medical errors that includes ideas and examples for health care leaders, and also illustrates that widespread improvements in patient safety are possible — even in a complex health care organization.

Crisis Communications: Medication Diversion Incident

Living Through a Sentinel Event Crisis: Lessons Learned

A presentation describing an event at Mt. Auburn Hospital that involves aberrant behavior and credentialing.

Novant Health: MRSA in the NICU

This speech by Novant Health President and CEO Paul Wiles describes an infant death in the neonatal intensive care unit due to MRSA infection.

Hospital President's Letter to Staff: An Unexpected Death in the Waiting Area

A letter from the president of New York Health and Hospitals Corporation to all staff that describes a much-publicized unexpected death in the Psychiatric ED waiting area and the hospital's response.

Virginia Mason Medical Center: Medication Labeling Error

This article describes how Virginia Mason Medical Center in Seattle responded to a preventable death from a medication labeling error. 

Serious Untoward Incident Panel Report

This report provides an expert review of the circumstances surrounding two maternal deaths at Winchester and Eastleigh Healthcare NHS Trust, England, in December 2007. 

Remedy of Error

Out of a deadly medical mistake at Hopkins Hospital sprang a patient-safety effort that has united a bereaved parent with malpractice lawyers, physicians, and nurses. Learn more about Sorrell and Josie King's story.

Disclosure and Apology: What's Missing? Advancing Programs That Support Clinicians

This report from Medically Induced Trauma Support Services (MITSS) gives guidance to health care organizations for establishing programs that provide emotional support to clinicians and staff members following adverse events.

Being Open: Communicating Patient Safety Incidents with Patients, Their Families and Carers

A collection of resources from the National Patient Safety Agency (UK), including a best practice guide, support materials, and multiple recorded webinars such as the one focused on boards and chief executives leading the implementation of being open.