Respectful Management of Serious Clinical Adverse Events 2nd ed – Institute for Healthcare Improvement – 2011

Posted on October 18, 2011. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety | Tags: , |

Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011.

“This white paper 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.

Every day, clinical adverse events occur within our health care system, causing physical and psychological harm to one or more patients, their families, staff (including medical staff), the community, and the organization. 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 risks of not responding to these adverse events in a timely and effective manner are significant, and 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 of regulatory action or lawsuits, and challenges by the media.”

… continues on the site

Federico F, Conway J. Planning for a clinical crisis: Next steps. Healthcare Executive. 2011 Nov/Dec;26(6):74-76.

“The response to the 2010 Institute for Healthcare Improvement white paper titled  has been remarkable, as detailed below.

This article presents a summary of the learning gained since the Institute for Healthcare Improvement white paper, Respectful Management of Serious Clinical Adverse Events, was first published in 2010. The challenges remaining for clinical crisis planning along with comments on four areas of crisis management that are receiving the greatest attention are also discussed.”


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