IHI Issues Guidelines for Managing Clinical Adverse Events
Priority 2: The Front-line Staff
- "Are there people and resources available to coach the staff involved as they prepare for disclosure of the event, and to support them through the process?"
- "Is there ongoing support to the clinicians and team at the front line of the harm? Are they at risk of personal harm? When are they safely able to return to providing care? Would it be helpful for the CEO to meet with the front-line staff?"
- "Do not jump to conclusions: Ask 'What happened?' and not 'Who did it?' "
The IHI team acknowledges that fighting off shame and blame is a huge challenge after serious events.
Priority 3: The Organization
- "There is a visible CEO ('I care,' 'I'm accountable')."
- "The organization has issued a call to action grounded in values, integrity and doing the right thing."
- "The board of trustees is notified, as are relevant regulatory agencies" and "a root cause analysis of the event has been activated immediately."
The 36-page paper includes a list of important words hospital officials should use to assure the public and staff understand that the hospital take responsibility and has absorbed the severity of the incident. It suggests CEOs use words or phrases of compassion, concern, empathy, and remorse, such as "alarmed, appalled, ashamed, and disappointed."
It also includes a list of 14 hospital CEOs willing to talk about tragic events at their institutions, including Rady Children's Hospital in San Diego, which grappled with incidents involving sexual abuse of children by employees.
Other parts of the paper deal with how to engage with the media.
Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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