Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.

Michelle M. Mello; Susan K. Senecal; Yelena Kuznetsov; Janet S. Cohn

Study

Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.

February 5, 2014

Mello MM, Senecal SK, Kuznetsov Y, et al. Health Aff (Millwood). 2014;33(1):30-8.

View more articles from the same authors.

This study reports on an AHRQ-funded effort to establish communication-and-resolution protocols for general surgery in five New York City hospitals. The participating hospitals improved their incident disclosure but also encountered many critical obstacles to full implementation.

PubMed citation

Available at

Related Resources From the Same Author(s)

Case outcomes in a communication-and-resolution program in New York hospitals.

February 1, 2017

How policy makers can smooth the way for communication-and-resolution programs.

January 29, 2014

Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate.

December 21, 2016

Ensuring successful implementation of communication-and-resolution programmes.

March 18, 2020

Medical malpractice liability in the age of electronic health records.

December 1, 2010

Legal and policy interventions to improve patient safety.

March 2, 2016

Improving reconciliation following medical injury: a qualitative study of responses to patient safety incidents in New Zealand.

October 4, 2017

Malpractice reform—opportunities for leadership by health care institutions and liability insurers.

April 14, 2010

Managing the risks of concurrent surgeries.

March 30, 2016

The evolving story of overlapping surgery.

July 19, 2017

The role of medical liability reform in federal health care reform.

July 1, 2009

Patient safety and medical malpractice: a case study.

March 6, 2005

Administrative compensation for medical injuries: lessons from three foreign systems.

August 3, 2011

The medical liability climate and prospects for reform.

November 19, 2014

Patients' experiences with communication-and-resolution programs after medical injury.

October 18, 2017

Apology laws and malpractice liability: what have we learned?

July 8, 2020

Disclosing harmful medical errors to patients: tackling three tough cases.

September 30, 2009

Medical monitoring for pharmaceutical injuries: tort law for the public's health?

March 6, 2005

Understanding liability risk from using health care artificial intelligence tools.

January 31, 2024

'Poking the skunk': ethical and medico-legal concerns in research about patients' experiences of medical injury.

July 17, 2019

Advising patients about patient safety: current initiatives risk shifting responsibility.

September 7, 2005

Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement.

February 6, 2008

The hidden costs of reconciling surgical sponge counts.

November 11, 2015

Malpractice liability and health care quality: a review

February 19, 2020

Changes in practice among physicians with malpractice claims.

April 3, 2019

Claims, errors, and compensation payments in medical malpractice litigation.

May 17, 2006

Fostering rational regulation of patient safety.

July 20, 2005

Can communication-and-resolution programs achieve their potential? Five key questions.

December 19, 2018

National costs of the medical liability system.

September 15, 2010

"Health courts" and accountability for patient safety.

September 13, 2006

Beyond negligence: avoidability and medical injury compensation.

October 31, 2007

Disclosure-and-resolution programs that include generous compensation offers may prompt a complex patient response.

December 19, 2012

Assessing patients 2019 experiences with medical injury reconciliation processes: item generation for a novel survey questionnaire.

May 5, 2021

Prevalence and characteristics of physicians prone to malpractice claims.

February 3, 2016

Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry.

September 14, 2005

Disclosure of medical injury to patients: an improbable risk management strategy.

January 24, 2007

Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation.

January 9, 2013

Using simulation to prepare nursing staff for the move to a new building.

April 26, 2017

Relationship between quality of care and negligence litigation in nursing homes.

April 13, 2011

Using the rapid response system to provide better oversight of patient care processes.

November 14, 2007

Priority patient safety issues identified by perioperative nurses.

May 8, 2013

Four states with robust prescription drug monitoring programs reduced opioid dosages.

June 27, 2018

Assessment of perioperative outcomes among surgeons who operated the night before.

June 8, 2022

Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.

June 8, 2005

Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs.

October 11, 2017

Collaboration with regulators to support quality and accountability following medical errors: the communication and resolution program certification pilot.

September 21, 2016

Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey.

October 14, 2015

Relationship between state malpractice environment and quality of health care in the United States.

April 12, 2017

Communication-and-resolution programs: the challenges and lessons learned from six early adopters.

January 15, 2014

Fixing broken bones and broken homes: domestic violence as a patient safety issue.

March 6, 2005

Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care.

November 16, 2016

Characteristics of quality and patient safety curricula in major teaching hospitals.

July 21, 2010

Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner.

September 26, 2007

Benefits of reporting and analyzing nursing students' near-miss medication incidents.

March 9, 2022

Talking with patients about other clinicians' errors.

November 6, 2013

Patient engagement in the inpatient setting: a systematic review.

December 18, 2013

Early death after discharge from emergency departments: analysis of national US insurance claims data.

February 15, 2017

Systems thinking for managing COVID-19 in health care systems: seven key messages.

September 23, 2020

Association of overlapping surgery with perioperative outcomes.

March 6, 2019

The link between clinically validated patient safety indicators and clinical outcomes.

January 10, 2018

Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs.

February 29, 2012

E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care.

October 31, 2012

e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approach.

July 31, 2013

Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing.

August 1, 2012

Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals.

March 4, 2009

Innovative approach to reconstruct bedside handoff: using simple rules of complexity science to promote partnership with patients.

May 30, 2018

Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System.

April 2, 2008

Effects of a communication-and-resolution program on hospitals' malpractice claims and costs.

December 19, 2018

Predictors of nursing home nurses' willingness to report medication near-misses.

May 13, 2020

Transforming concepts in patient safety: a progress report.

August 1, 2018

Examining markers of safety in homecare using the international classification for patient safety.

June 12, 2013

How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England.

August 23, 2017

Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients.

October 10, 2012

Promethazine adverse events after implementation of a medication shortage interchange.

April 15, 2005

Rates and types of events reported to established incident reporting systems in two US hospitals.

June 20, 2007

White paper on recommendation for systems-based practice competency.

December 6, 2017

Implementation of a rapid response team: a success story.

June 17, 2009

Using a potentially aggressive/violent patient huddle to improve health care safety.

January 30, 2019

The relationships among work stress, strain and self-reported errors in UK community pharmacy.

March 19, 2014

Bullying of junior doctors prevails in Irish health system: a bitter reality.

December 7, 2005

Electronic patient identification for sample labeling reduces wrong blood in tube errors.

March 20, 2019

Documentation of clinical review and vital signs after major surgery.

October 29, 2008

Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology.

October 15, 2014

Exploring attitudes and opinions of pharmacists toward delivering prescribing error feedback: a qualitative case study using focus group interviews.

November 4, 2015

Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospital setting.

January 16, 2019

Contributing factors identified by hospital incident report narratives.

October 22, 2008

Interventions to reduce burnout and improve resilience: impact on a health system's outcomes.

June 12, 2019

Nursing handoffs: a systematic review of the literature.

April 21, 2010

Automated dispensing cabinets.

August 15, 2007

How do community pharmacies recover from e-prescription errors?

January 7, 2015

E-prescribing errors in community pharmacies: exploring consequences and contributing factors.

April 16, 2014

The culture of safety: results of an organization-wide survey in 15 California hospitals.

March 6, 2005

Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses.

August 10, 2016

The Second Victim Experience and Support Tool: validation of an organizational resource for assessing second victim effects and the quality of support resources.

October 22, 2014

Validating administrative data for the detection of adverse events in older hospitalized patients.

October 29, 2014

Exploring error in team-based acute care scenarios: an observational study from the United Kingdom.

June 6, 2012

Understanding the behaviour of newly qualified doctors in acute care contexts.

November 2, 2011

Nurse sensemaking for responding to patient and family safety concerns.

March 17, 2021

Teamwork on inpatient medical units: assessing attitudes and barriers.

May 5, 2010

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety.

December 19, 2007

Related Resources

Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events.

June 28, 2023

Ambulatory Surgery Center Survey on Patient Safety Culture.

May 29, 2023

Development and interrater agreement of a novel classification system combining medical and surgical adverse event reporting.

April 19, 2023

Annual Perspective

Annual Perspective: Psychological Safety of Healthcare Staff

March 31, 2022

The effects of harm events on 30-day readmission in surgical patients.

April 15, 2020

Analysis of human performance deficiencies associated with surgical adverse events.

August 14, 2019

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.

July 10, 2019

How one health system overcame resistance to a surgical checklist.

May 29, 2019

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

May 8, 2019

Quality improvement in ambulatory surgery centers: a major national effort aimed at reducing infections and other surgical complications.

March 27, 2019

Endorsements of surgeon punishment and patient compensation in rested and sleep-restricted individuals.

March 27, 2019

Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery.

March 13, 2019

Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes.

March 6, 2019

Association of overlapping surgery with perioperative outcomes.

March 6, 2019

Comparing the outcomes of reporting and trigger tool methods to capture adverse events in the emergency department.

February 27, 2019

Evaluation of a patient safety programme on Surgical Safety Checklist compliance: a prospective longitudinal study.

August 15, 2018

Identifying quality markers of a safe surgical ward: an interview study of patients, clinical staff, and administrators.

May 2, 2018

Leading article: how can I optimise my role as a leader within the surgical team?

August 31, 2016

Promoting patient safety with perioperative hand-off communication.

August 10, 2016

An innovative approach to the surgical time out: a patient-focused model.

June 29, 2016

Use of personal electronic devices by nurse anesthetists and the effects on patient safety.

May 25, 2016

A 'paperless' wall-mounted surgical safety checklist with migrated leadership can improve compliance and team engagement.

January 27, 2016

Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.

August 5, 2015

The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 'near-misses' and adverse events.

February 25, 2015

Assessing distractors and teamwork during surgery: developing an event-based method for direct observation.

October 29, 2014

Another surgeon's error: must you tell the patient?

October 15, 2014

National pediatric anesthesia safety quality improvement program in the United States.

October 1, 2014

Trade-offs between voice and silence: a qualitative exploration of oncology staff's decisions to speak up about safety concerns.

September 17, 2014

Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study.

July 23, 2014

Distractions in the operating room.

June 18, 2014

See More About The Topic

Operating Room

Physicians

Nurses

Health Care Executives and Administrators

Organizational Behaviorists

Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site