IHI Issues Guidelines for Managing Clinical Adverse Events

Cheryl Clark, October 4, 2010

The call wakes the hospital CEO at 3:00 AMA patient has died because of a terrible medical error," he is told. "The family is upset and talking with a reporter. The nurses and doctors are pointing fingers. This looks very bad for us. What should we do?"


Versions of this chaotic scenario happen with increasing frequency in many healthcare facilities nationally. But "many organizations do not have a plan for when a serious clinical adverse event occurs," says Jim Conway, senior fellow with the Institute for Healthcare Improvement.

In a white paper "Respectful Management of Serious Clinical Adverse Events"  released Friday, Conway and colleagues with IHI and the Harvard School of Public Health offer a way for providers to prepare.

Conway has firsthand experience with the dos and don'ts of crisis management. He was chief operating officer at Dana Farber Cancer Institute in Boston in 1994 when 39-year-old Boston Globe health reporter Betsy Lehman died of complications from a chemotherapy overdose she received while undergoing breast cancer treatment there.

Conway, who learned many lessons during and after that event, has devoted the rest of his career to improving organizational safety and transparency.

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