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Respectful Management of Serious Clinical Adverse Events
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This white paper introduces an overall approach and tools designed to support two processes: the proactive preparation of a plan for managing serious clinical adverse events, and the reactive emergency response of an organization that has no such plan.
Doing Right by Our Patients When Things Go Wrong in the Ambulatory Setting
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The PROMISES Project (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction) released this statement, suggesting that disclosure and apology are essential first steps to learning from medical errorsthat may have harmed patients and families. The accompanying "Guidelines for Responding to Adverse Events" present practical tips and FAQs.
Disclosure Toolkit and Disclosure Culture Assessment Tool
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The toolkit and assessment tool help health care organizations develop a culture that supports respect and effective communication with patient and families around adverse events; developed by the Institute for Healthcare Improvement (Cambridge, Massachusetts, USA).
WIHI: Adverse Events and Their Aftermath: SOS from Clinicians
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February 4, 2010 | As organizations develop more accountable and transparent ways to interact with families and patients who've been harmed by medical care, the emotional and professional needs of doctors, nurses, and staff — whether directly or indirectly involved in an incident — also need to be addressed.
WIHI: Message to Managers: Crises Happen. Plan Ahead!
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March 4, 2010 | One key to effective crisis management is being prepared with a response system that everyone is familiar with and knows how to activate – before bad things occur. Three national improvers, well versed in risk management, discuss how they are actively reframing the priorities to be patient-centered, most of all.
WIHI: Reports from the Frontlines of Effective Crisis Management
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April 7, 2011 | Two hospital leaders join a co-author of the IHI white paper, "Respectful Management of Serious Clinical Adverse Events," to discuss what they learned, in real time, about the critical importance of making crisis management a part of every organization’s culture of quality and safety.
WIHI: Reliable Practices for Responding to Natural Disasters: Lessons from Long Island Jewish and Hurricane Sandy
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May 16, 2013 | This WIHI looks at how health care organizations and first responders prepare for crises and disasters, and provides perspectives from leaders at North Shore-LIJ Health System who were responsible for every kind of decision imaginable before, during, and after Hurricane Sandy.
Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management
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A collection of leadership resources assembled from organizations that experienced and learned from a serious organizational event, most often a significant medical error, that also describe how they managed the crisis and developed safer systems in response.
Supporting Involved Health Care Professionals (Second Victims) Following an Adverse Health Event: A Literature Review
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Based on an extensive review, the authors found numerous supportive actions for second victims described in the literature.
Adverse Clinical Outcome Disclosure Plans Aid Response Efforts, Reduce Liability Risks
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This article discusses efforts to support the need for a comprehensive plan to proactively manage medical mistakes.
Planning for a clinical crisis
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This article presents key elements of clinical crisis management and practical guidance to help organizational leaders develop effective plans for managing such events.
Planning for clinical crisis: Next steps
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This article presents a summary of the learning gained and the challenges remaining for clinical crisis planning, along with comments on four areas of crisis management that are receiving the greatest attention.
What happens when things go wrong?
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What happens to the family of the injured pediatric patient and to the health care providers after an adverse event involving anesthesia occurs?