IHI Issues Guidelines for Managing Clinical Adverse Events

"The risks of not responding to these adverse events in a timely and effective manner are significant," he and his colleagues wrote. The ramifications include:

•  Loss of trust
•  Absence of healing
•  No learning and improvement
•  The sending of mixed messages about what is really important to the organization.
•  Increased likelihood for regulatory action or lawsuits
•  Increased likelihood of challenges by the media.

"For any organization, the fact that these events occur doesn't differentiate tem," the authors wrote in the introduction.

"In the crisis that often emerges, what differentiates organizations, positively or negatively, is their culture of safety, the role of the board of trustees and executive leadership, advanced planning for such an event, the balanced prioritization of the needs of the patient and family, staff and organization, and how actions immediately and over time bring empathy, support, resolution, learning and improvement."

The paper is divided into sections offering sample plans, questions to ask about preparedness, and checklists. For example:
Priority 1: The Patient and Family

• "Has there been appropriate communication and disclosure to the patient and family, most often by a team of two staff persons (or in some cases more), including a clinician who has a pre-established relationship with them?"
• "Has the organization made a statement of empathy and issued an apology in cases where there is fault?"