New Patient Safety White Paper from IHI available

The Institute for Healthcare Improvement has released a new white paper in the IHI Innovation Series titled Respectful Management of Serious Clinical Adverse Events.

The paper is available on the IHI website for free download at www.ihi.org/IHI/Results/WhitePapers. The paper was released and presented at the National Association for Healthcare Quality (NAHQ) 35th Annual Educational Conference in Kansas City, Missouri, on October 1, 2010.

The paper addresses the importance of having a tested crisis management plan in place to respond to the clinical adverse events, and provides specific guidance and tools for developing such a plan.

The risks of not responding to these events in a timely and effective manner are significant. They include the loss of trust, absence of healing, no learning and improvement, sending mixed messages about what is really important to the organization, increased likelihood of regulatory action or lawsuits, and challenges by the media.

IHI developed the white paper in response to numerous requests from organizations seeking assistance in the aftermath of an adverse event. The most striking aspect of these requests is that the organization's response is often being built from scratch, in a reactive mode, rather than from an existing clinical crisis management plan. To respond effectively to these types of requests, IHI draws on patient- and family-centered care, patient safety, crisis management, and disaster planning, and on the experiences of health care organizations that have attempted to manage such crises in a respectful and effective manner. This IHI white paper:

• encourages and helps every organization to develop a clinical crisis management plan before they need to use it;
• provides an approach to integrate this plan into the organizational culture of quality and safety, with a particular focus on patient- and family-centered care and fair and just treatment for staff; and
• provides organizations with a concise and practical resource to inform their efforts when a serious adverse event occurs in the absence of an organizational clinical crisis management plan or culture of quality and safety.

  

Common Format for Adverse Event Reporting on Health Information Technology

The Agency for Healthcare Research and Quality (AHRQ) has released a new Common Format designed to help healthcare providers collect information about adverse events related to HIT. This Common Format, entitled Device or Medical/Surgical Supply including HIT Device, is currently available as a beta version for public review and comment. The format will be revised based on feedback and released with Common Formats, Version 1.2 in August 2011.

The Agency has contracted with the National Quality Forum (NQF) to assist with gathering and analyzing feedback on this Common Format. The NQF tool to post comments about the Device or Medical/Surgical Supply including HIT Device Common Format is available at http://www.qualityforum.org/projects/commonformats.aspx.

AHRQ appreciates the time and effort individuals invest in providing comments. All feedback received will be reviewed and considered to guide the development of a revised version.

To subscribe to Patient Safety & Quality Healthcare magazine please visit www.psqh.com

Planning For Medical Adverse Effects

As much as we’d like to think that we can “get to zero” for all recurring medical errors, mistakes and adverse events will be part of medicine for the foreseeable future. In addition to working on prevention and mitigation of harm, clinicians and healthcare organizations should work on planning for the inevitable, in order to minimize harm and promote healing. Patients and families will benefit, too, if indirectly from these efforts.

Three new resources reflect the experience of clinicians and healthcare organizations following adverse events and offer practical advice and tools to minimize harm for all concerned:

Healing the Healer is a documentary film from CRICO/RMF that uses interviews and case studies to show the emotional impact of adverse events on clinicians. Click here for a preview and ordering information.?

The latest title in IHI’s Innovation Series white papers, Respectful Management of Serious Clinical Adverse Events, is available for free download. This report “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.”?

In “Doctors Confess Their Fatal Mistakes,” Reader’s Digest presents first-person accounts of serious errors from Peter Pronovost, Eric Cropp, Bob Wachter, and others. The article reflects a sophisticated understanding of patient safety principles and is intended for a broad audience.