The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55:43-103.
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.
… claims. This article discusses the possibility of a medical malpractice crisis in response to poor outcomes … that could prevent traditional legal actions. … Sage WM, Boothman RC, Gallagher TH. Another medical malpractice …
Aboumrad M, Carluzzo KL, Lypson ML, et al. Acad Med. 2020;95.
A survey of Veteran’s Affairs Chief Resident in Quality and Safety (CRQS) program alumni suggests that such programs can teach residents to lead and engage other residents in patient safety and ultimately lead to a workforce fostering a culture of safety. Reported barriers included lack of time and difficulty prioritizing safety work given other clinical responsibilities.
Mello MM, Boothman RC, McDonald TB, et al. Health Aff (Millwood). 2014;33:20-29.
When a patient is a victim of an error, hospitals have traditionally followed a "deny and defend" strategy, providing limited information to the patient and family and avoiding admissions of fault—or even admission that an error occurred. This approach has long been criticized for its lack of patient-centeredness, and in response some institutions have begun to implement communication-and-response strategies that emphasize early disclosure of adverse events and proactive attempts to resolve the situation. This study reviews six institutions' experiences with two types of communication-and-response strategies: early settlement programs (in which errors are fully disclosed and an offer of compensation is made, along with investigation of safety issues) and limited reimbursement programs (which provided limited compensation to patients with concerns about their care, but explicitly exclude more severe errors). Through structured interviews with key participants, the authors identify crucial regulatory, legal, and practical issues with implementing these programs. They emphasize that such programs should be viewed as part of an effort to improve safety culture and that transparency and a blame-free approach are essential to obtaining support (especially from physicians). The complex intersection between error disclosure and malpractice is explored further in an AHRQ WebM&M perspective.
Bell SK, Smulowitz PB, Woodward AC, et al. Milbank Q. 2012;90:682-705.
… … Milbank Q … Some hospital systems have employed a disclosure , apology, and offer strategy for medical … for more widespread implementation of this model, despite a lack of generalizable data. Benefits for both the liability …
Ross PT, McMyler ET, Anderson SG, et al. Jt Comm J Qual Patient Saf. 2011;37:88-95.
… prevention. More than 25% of surveyed trainees witnessed a failure of supervision, which were categorized into three … The authors explore their findings in the context of a call for new educational paradigms , establishing a culture of safety , and management of disruptive behavior . …
Kachalia A, Kaufman SR, Boothman RC, et al. Ann Intern Med. 2010;153:213-21.
Physicians generally choose their words carefully when disclosing errors to patients, in large part due to fear of malpractice lawsuits. Proponents of full disclosure of errors have argued that such policies could actually decrease lawsuits by encouraging more open provider–patient communication and more fairly compensating patients for injuries. This strategy has been controversial and thus far has lacked supporting evidence, but the experiences of the University of Michigan Health System reported in this study may change attitudes toward error disclosure. In 5 years since implementing a full disclosure and compensation policy, the system has seen fewer lawsuits and lower costs related to litigation and compensation. The accompanying editorial discusses the systematic changes that will be necessary in order to make the Michigan model more generalizable.