A Quiet Revolution: Communicating and Resolving Patient Harm
Good patient care includes not only avoiding error and injury but also acting honestly and constructively should it occur. Communication and Resolution Programs (CRPs) commit the sponsoring institution to vigilant detection of error, full disclosure to patients and families, and timely redress. CRPs also seek to incorporate the perspectives of patients and family members into safety improvement activities. This chapter explains the principles underlying CRPs, traces their history, and describes current best practices for physicians, provider organizations, and the legal and regulatory environment. Transparency about error and proactive response to injury lagged other professional commitments to patient self-determination because of the emotion and politics surrounding medical malpractice. However, recent generations of physicians, patients, and policymakers have engineered a “quiet” revolution. Silence and secrecy are no longer ethically acceptable responses to medical error. Although additional research is needed on how CRPs affect safety, patient and provider satisfaction, and cost, the American College of Surgeons in 2014 declared CRPs to be, on balance, the most promising approach to medical liability reform.
KeywordsCommunication and resolution Medical error Malpractice Patient safety Disclosure Transparency
The authors thank medical student Adam Hensley, University of Texas Medical Branch, for research assistance. The authors extend special thanks to Dr. Tom Gallagher at the University of Washington for providing detailed, current information about CRP initiatives nationwide.
- 2.Classen DC, et al. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff. 2011;30:581–9.Google Scholar
- 6.Iezzoni LI, Rao SR, DesRoches CM, Vogel C, Campbell EG. Survey shows that at least some physicians are not always open or honest with patients. Health Aff. 2012;31(2):383–91.Google Scholar
- 8.Barach P, Cantor M. Adverse event disclosure: benefits and drawbacks for patients and clinicians. In: Clarke S, Oakley J, editors. The ethics of auditing and reporting surgeon performance. Cambridge: Cambridge Press; 2007. p. 76–91. ISBN 9780521687782.Google Scholar
- 9.American College of Surgeons. Statement on medical liability reform. 2015. https://www.facs.org/about-acs/statements/77-medical-liability-reform.
- 11.Collaborative for accountability and improvement. 2015. http://communicationandresolution.org/communication-and-resolution-programs/the-essentials/.
- 12.Cantor M, Barach P, Derse A, Maklan C, Woody G, Fox E. Disclosing adverse events to patients. Jt Comm J Qual Saf. 2005;31:5–12.Google Scholar
- 13.Etchegaray JM, Ottosen MJ, Burress L, Sage WM, Bell SK, Gallagher TH, Thomas EJ. Structuring patient and family involvement in medical error event disclosure and analysis. Health Aff. 2014;33(1):46–52.Google Scholar
- 23.Johnson J, Haskell H, Barach P, editors. Case studies in patient safety: patients and providers. Burlington: Jones and Bartlett Learning; 2015. ISBN 81449681548.Google Scholar
- 24.Sage WM. Relating health law to health policy: a frictional account. In: Cohen IG, Hoffman A, Sage WM, editors. Oxford Handbook of US Health Law. New York: Oxford University Press; 2016.Google Scholar
- 25.Black B, Silver C, Hyman DA, Sage WM. Stability, not crisis: medical malpractice claim outcomes in Texas, 1988–2002. J Empir Leg Stud. 2005;2(2):207–59.Google Scholar
- 28.Grady MF. Why are people negligent?: technology, nondurable precautions, and the medical malpractice explosion. Northwest Univ Law Rev. 1988;82:293–334.Google Scholar
- 30.Sage WM. Reputation, malpractice liability, and medical error. In: Sharpe VA, editor. Accountability: patient safety and policy reform. Washington, DC: Georgetown University Press; 2004. p. 159–83.Google Scholar
- 31.Sage WM, Jablonski JS, Thomas EJ. Use of non-disclosure agreements in medical malpractice settlements by a large academic health care system. JAMA Intern Med. 2015;175(7):1130–5. doi: 10.1001/jamainternmed.2015.1035, published online May 11, 2015.
- 32.Mello MM, Boothman RC, McDonald T, Driver J, Lembitz A, Bouwmeester D, Dunlap B, Gallagher T. Communication-and-resolution programs: the challenges and lessons learned from six early adopters. Health Aff. 2014;33(1):20–9.Google Scholar
- 33.Truog RD, Browning DM, Johnson JA, Gallagher TH, Leape LL. Talking with patients and families about medical error: a guide for education and practice. Baltimore, MD: Johns Hopkins University Press; 2011.Google Scholar
- 37.Department of Veterans Affairs. Final rule, policy regarding participation in National Practitioner Data Bank, 67(78) Fed. Reg. 19678. 2002.Google Scholar
- 41.Robeznieks A. Full disclosure first: alternative med-mal approaches show promise. Modern Healthcare; 2 Feb 2013. http://www.modernhealthcare.com/article/20130202/MAGAZINE/302029954.
- 42.COPIC’s 3R program newsletter. 2006;3(1). http://www.slideshare.net/patrick89/copics-3rs-program-newsletter-volume-3-issue-1-june-2006.
- 43.Institute of Medicine. Fostering rapid advances in health care: learning from system demonstrations (Corrigan JM, Greiner A, Erickson SM, editors). Washington, DC: National Academies Press; 2002.Google Scholar
- 44.Joint Commission. Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury. 2005. https://www.jointcommission.org/assets/1/18/Medical_Liability.pdf.
- 45.National Quality Forum. Safe practices for better healthcare—2009 update: a consensus report. Washington, DC: NQF; 2009.Google Scholar
- 46.American Medical Association. Opinion 8.121—ethical responsibility to study and prevent error and harm. 2003.Google Scholar
- 47.Institute of Medicine. Improving diagnosis in health care (Balogh EP, Miller BT, and Ball JR, editors). Washington, DC: National Academies Press; 2015.Google Scholar
- 48.Liebman CB, Hyman CS. Medical error disclosure, mediation skills, and malpractice litigation: a demonstration project in Pennsylvania. New York: Project on Medical Liability in Pennsylvania; 2005.Google Scholar
- 50.Liebman CB, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Aff. 2004;23:422–32.Google Scholar
- 51.Barach P, Wolfson J, Stark S, Glass L. Establishing a Florida patient safety network. Report submitted to the Florida Agency for Health Care Administration (AHCA), 29 June 2004.Google Scholar
- 53.Corrigan JM, Greiner A, Erickson SM, editors. Fostering rapid advances in health care: learning from system demonstrations. Washington, DC: National Academies Press; 2002.Google Scholar
- 54.Agency for Healthcare Research and Quality. Medical liability reform and patient safety initiative (Internet). Rockville, MD: AHRQ; 2012. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/liability/index.html. Accessed 9 Dec 2013.
- 55.Agency for Healthcare Research and Quality. Demonstration grants (Internet). Rockville, MD: AHRQ; 2010. http://www.ahrq.gov/qual/liability/demogrants.htm. Accessed 4 Dec 2013.
- 56.Mello MM, Senecal SK, Kuznetsov Y, Cohn JS. Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. Health Aff. 2014;33(1):30–8.Google Scholar
- 57.Hendrick A, McCoy CK, Gale J, Sparkman L, Santos P. Ascension Health’s demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise. Health Aff. 2014;33(1):39–45.Google Scholar
- 58.Full Disclosure Working Group. When things go wrong: responding to adverse events. A consensus statement of the Harvard Hospitals. Boston: Massachusetts Coalition for the Prevention of Medical Errors; 2006.Google Scholar
- 59.Massachusetts Alliance for Communication and Resolution Following Medical Injury (MACRMI). About CaRE. 2015. http://www.macrmi.info/about-macrmi/about-dao/#sthash.dvKmNie8.dpbs.
- 60.Conway J, Federico F, Stewart K, Campbell M. Respectful management of serious clinical adverse events, IHI Innovation Series white paper. 2nd ed. Cambridge, MA: Institute for Healthcare Improvement; 2011.Google Scholar
- 61.Marx D. Patient safety and the “Just Culture”: a primer for health care executives. New York: Columbia University; 2001.Google Scholar
- 63.Gilula M, Barach P. Designing a patient safety curriculum. In: Sheikh A, Hurwitz B, editors. Health care errors and patient safety. London: Wiley-Blackwell; 2009. p. 238–53. ISBN 9781405146432.Google Scholar
- 64.Sage WM, Gallagher TH, Armstrong S, Cohn J, McDonald T, Gale JL, Woodward A, Mello MM. How policy makers can smooth the way for communication-and resolution programs. Health Aff. 2014;33(1):11–9.Google Scholar
- 65.Medical Quality Assurance Commission (State of Washington). Guidelines: endorsement of just culture principles to increase patient safety and reduce medical errors. 2014.Google Scholar
- 66.Medical Quality Assurance Commission (State of Washington). Guideline: a collaborative approach to reducing medical error and enhancing patient safety (MD2015-08). 2015.Google Scholar
- 67.Oregon Patient Safety Commission. Oregon collaborative on communication and resolution programs. 2015. http://oregonpatientsafety.org/discussion-resolution/discussion-resolution/OCCRP/1849.
- 68.National Practitioner Data Bank. NPDB guidebook. 2015. http://www.npdb.hrsa.gov/resources/npdbguidebook.pdf.