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:
Sample Crisis Management Plans
IHI is grateful to organizations for sharing their crisis management plans, and to the individuals in those organizations who are willing to be contacted, to further our collective learning.
Are you willing to share your organization's crisis management plan? Please email Frank Federico at IHI (
ffederico@ihi.org).
Brant Community Healthcare System
Catholic Healthcare Partners
Christiana Care Health System
Kaiser Permanente
MemorialCare Health System
Bibliographies
Audio and Video Resources
WIHI: Reports from the Frontlines of Effective Crisis Management (April 7, 2011): Jim Conway, Anthony Armada, Michael Fisher, Uma Kotagal, Michelle Hoppes
WIHI: Message to Managers: Crises Happen. Plan Ahead! (March 4, 2010): Jim Conway, Timothy McDonald, Richard Boothman
WIHI: Adverse Events and Their Aftermath: SOS from Clinicians (February 4, 2010): Albert Wu, Linda Kenney, Susan D. Scott
Chasing Zero: Winning the War on Healthcare Harm
From Tears to Transparency Series: The Story of Lewis Blackman
Healing the Healer
Health Care for All: Consumer Health Quality Council Stories of Harm
The Josie King Story DVD
Presentations, Publications, and Case Studies
A presentation by former IHI Senior Vice President Jim Conway that distills learning about crisis management from other organizations' experiences, the literature, and experts in this field.
Joint presentation to the Centers for Medicare & Medicaid Services from the Massachusetts Department of Public Health and the Dana-Farber Cancer Institute on their joint management and learning after the Betsy Lehman Chemotherapy Error.
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.
This 2011 Health Affairs article by Blair Sadler describes an effective response to a crisis at Rady Children's Hospital in San Diego.
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.
A presentation describing an event at Mt. Auburn Hospital that involves aberrant behavior and credentialing.
This speech by Novant Health President and CEO Paul Wiles describes an infant death in the neonatal intensive care unit due to MRSA infection.
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 IncidentThis article describes the comprehensive crisis communication plan involving internal and external audiences that was implemented by Immanuel St. Joseph’s — Mayo Health System after discovering that an employee was tampering with narcotics.
Virginia Mason Medical Center: Medication Labeling ErrorThis article describes how Virginia Mason Medical Center in Seattle responded to a preventable death from a medication labeling error.
The Crisis We Hoped Would Never HappenThis presentation provides an overview of the circumstances surrounding two maternal deaths at Winchester and Eastleigh Healthcare NHS Trust, England.
Remedy of ErrorOut 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.
Federico F, Conway J. Healthcare Executive. 2011 Nov/Dec;26(6):74-76.
McCrary M, Byers A. Trustee magazine. September 2010.
This article describes how Sandra Coletta, CEO of Kent Hospital in Rhode Island, apologized for errors that caused the death of Michael Woods, and how she initiated steps to redesign systems to prevent future errors.
Tools
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.
Tools from the IHI white paper, Respectful Management of Serious Clinical Adverse Events: Checklist, Work Plan, and Disclosure Culture Assessment Tool. These three tools appear as appendices in the IHI white paper and are included here as individual documents for ease of use.
Tools for Building a Clinician and Staff Support Program
A collection of tools to support clinicians and staff following an adverse event, assembled by MITSS (Medically Induced Trauma Support Services).
Disclosure of Unanticipated Medical Outcomes: Guidelines for Health Care Professionals
This pamphlet was developed by Advocate Lutheran General Hospital.
Other Resources
A blog post by Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, about a wrong-sided surgery event.
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.