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Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
Web Resource > Multi-use Website
Tanya and Phil Barnett.
This Web site includes a video chronicling how an undiagnosed heart condition led to a teenager's death and offers tips for patients to prevent medical errors.
VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete.
Washington, DC: United States Government Accountability Office; October 28, 2011. Publication GAO-12-6R.
This report reviews injury claim data to assess quality of care in the Veterans Affairs health system.
Web Resource > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality.
This website disseminates information regarding an AHRQ-funded initiative to implement and evaluate medical liability reform improvements that support safe patient care.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Full disclosure programs have shown to be effective mechanisms for early resolution of adverse events. This article reveals one early adopter's experience with full disclosure and provides insights from the architects of the program to guide others in implementing similar strategies and spread success associated with the approach.
VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.
Washington, DC: United States Government Accountability Office; May 2006. Publication GAO-06-648.
This report reviews findings from a federal inspection indicating that Veterans Affairs (VA) facilities, while complying with basic credentialing policies, are not routinely submitting malpractice data as required to be used by the VA to inform privileging determinations.