Communication and Resolution Programs

Abstract

A systems approach to patient safety is a relatively recent approach. The modern patient safety movement is generally thought to have started with the 1994 publication of Lucian Leape’s Error in Medicine, or for others even later with the Institute of Medicine’s To Err is Human published in 2000. Appreciation for the impact clinical culture has on safety and systems thinking described by the “science of safety,” “high reliability,” “Just Culture,” and others have evolved since; what has not evolved however, is the way medicine responds to patient harm. Aptly described “deny and defend” is not only ineffective for its singular purpose, litigation avoidance, but also it is counterproductive to the clinical mission, effectively undermining the values and practices of most modern patient safety strategies.

Communication and Resolution Programs (CRPs) conspicuously align organizational and personal responses to patients who suffer unintended clinical outcomes with the clinical mission and complement essential qualities of modern patient safety improvement. CRPs proactively respond to the individual patient harmed with compassion and nonnegotiable honesty, while decisively moving to protect against similar harm to other patients. CRPs accelerate improvement and promote a clinical culture of safety while happily saving professional liability costs. They are an indispensable component of any modern patient safety program.