Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management

​Institute for Healthcare Improvement
Cambridge, Massachusetts, USA

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 several resources:
  • An IHI Open School online course: Responding to Adverse Events 
  • 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.


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).
Catholic Healthcare Partners
Christiana Care Health System
MemorialCare Health System




Overview 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



Presentations, Publications, Case Studies, and Other Resources

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.

In this thought paper, the authors review the management of serious clinical crises in the United States, lessons learned from other industries, the draw on their own experiences from their roles as hospital leaders in the US and the UK.
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. See also the accompanying Letters published in Health Affairs:
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 preventable death due to a medical error strengthens Catholic Healthcare Partners' commitment to building a culture of safety. 

The Crisis We Hoped Would Never Happen
This presentation provides an overview of the circumstances surrounding two maternal deaths at Winchester and Eastleigh Healthcare NHS Trust, England. 
Planning for a Clinical Crisis
Conway JB, Sadler BL, Stewart K. Planning for a clinical crisis. Healthcare Executive. 2010 Nov/Dec;25(6):78-81.
Federico F, Conway J. Healthcare Executive. 2011 Nov/Dec;26(6):74-76.
McCrary M, Byers A. Trustee magazine. September 2010.
Adverse Clinical Outcome Disclosure Plans Aid Response Efforts, Reduce Liability Risks
Sturges PM. Adverse clinical outcome disclosure plans aid response efforts, reduce liability risk. BNA's Health Law Reporter. 12 HLR 823. June 12, 2012.
Seys D, Scott S, Wu A, Van Gerven E, et al. Supporting involved health care professionals (second victims) following an adverse health event: A literature review. International Journal of Nursing Studies. 2012 Jul 27. [Epub ahead of print]
A blog post in July 2008 by Paul Levy, then serving as 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.


Through the Eyes of Patients and Family Members

To enrich the resources for supporting respectful management of serious clinical adverse events, IHI has compiled articles and other media authored by or featuring patients or family members in the aftermath of such events. Resources are intended to inform and guide as well as to serve as case studies that can be used by organizations and instructors in crisis management planning. Every effort has been made to obtain free access to the publications.
Articles and Books
A mother, Johanna Back, writes on the tragic implications to her daughter, Chloe, of a tubing misconnection and her advocacy moving forward.
John James tells the story of how his son, Alex, died under the care of cardiologists, how the system failed to respond in any substantive way, and how to fix the system so others do not have similar experiences.
Mrs. Welch, a woman with cancer, dies after receiving poor care for an infection. Her physician-son, Jonathan Welch, calls on the health system to involve patients and families in improving safety.
Medically Induced Trauma Support Services (MITSS) was developed by a patient and an anesthesiologist involved in the unanticipated event that seriously harmed the patient. Linda Kenney and Rick Van Pelt, MD, tell the story of that event and the journey forward.
A father writes anonymously about the death of his daughter, Julia, offering his perspective on the system that broke down and efforts to reduce medical errors.
A family describes how diagnostic and medication errors led to a temporary coma. The article features the views of both the patient, Shirley Adams, and her husband, Robert, and an accompanying editorial discusses disclosing errors to patients.
Barbara Farlow describes a painful and tragic story of Annie, her daughter, and the care she received after her birth with Trisomy 13.
Dan Ford, a health care professional, describes the tragic journey his wife and family were on in the aftermath of medical error. He also outlines the learning journey that follows — one that is compassionate, safe, and accessible.
Doug Wojcieszak lost his oldest brother, Jim, to medical errors in 1998 and his family successfully sued the hospital and doctors, with the case settling in 2000. In this article the hospital’s response after Jim’s death is looked at through the lens of Jim and Doug’s father, a senior engineer.
This commentary by Dale Micalizzi, the mother of Justin, and Marie Bismark, a patient safety leader, outlines a service recovery model to help providers communicate effectively with patients and their families after an adverse event.
Lenore Alexander shares the story of her daughter Leah’s death that could have been prevented by monitoring. She never received an apology.
Video and Other Story Resources
The story of the tragic death of a young man, Tyler Kahle, after coming to the hospital for treatment. He died from an undetected rupture inside his chest — a tearing of the aorta called thoracic aortic dissection. In partnership with Tyler’s family, Methodist Health System is working to raise awareness and help health care providers understand and act on the knowledge that aortic dissection can occur at any age.
One video chronicles the experiences of a vibrant, healthy 15-year-old boy, Lewis Blackman, who entered the hospital for what was believed to be a low-risk medical procedure; he died several days later as the result of a series of medical errors. In another video, viewers are compelled to rethink the critical role that shared decision-making and informed consent play in patient safety and transparency through the lens of Michael Skolnik, who died at age 25 after a three-year ordeal following brain surgery.
Their stories show how systemic problems in the quality of health care can have a permanent impact on lives.
Communication failures and the lack of listening have caused irreparable harm in the lives of countless patients. While these errors are not intentional, they are preventable. The critical issue of listening is examined through the stories of several patients whose loved ones have been injured in the health care system.
A collection of stories assembled by the Canadian Patient Safety Institute.
A series of films collected by the World Health Organization. Films from the PAHO, SEARO, and EURO regions focus on past workshops and interviews with individual patient champions in the regions, while the Global Champions film brings together a selection of interviews from patient champions from across the regions. A number of films focus on specific issues.
Susan Sheridan speaks on how medical errors impacted her family and forever changed her life. Her son experienced brain damage at birth as a result of failure to do adequate newborn testing, and her husband was misdiagnosed with a spinal tumor that eventually took his life.
Profiles the preventable death of Josie King while under hospital care after the 18-month-old suffered second-degree burns. Underscored are the efforts of her mother, Sorrel King, her family, and friends for accountability, learning, and improvement.
Linda Kenney, the patient, and Dr. Rick van Pelt, her physician, tell the story of her tragic medical error that led from near death to healing and the formation of a national organization (MITSS) to support patients, family members, and staff in the aftermath of adverse events.
This short film by Transparent Health and SolidLine Media shares information with the health care consumer on what happens when a medical error occurs.
A complete educational package of videos and other materials from Harvard’s CRICO/RMF that delivers a profound opportunity for health professionals to increase their understanding of the patient and family experience and make changes in how health care is delivered.



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).  

Communication and Optimal Resolution (CANDOR) Toolkit
Health care institutions and practitioners can use the CANDOR process to respond in a timely, thorough, and just way when unexpected events cause patient harm. The CANDOR toolkit from the Agency for Healthcare Research and Quality contains eight different modules, each containing PowerPoint slides with facilitator notes. Some modules also contain tools, resources, or videos.

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