Updated advice for adverse events

Second edition of IHI paper won't be last reissue

In the year since it was published by the Institute for Healthcare Improvement, there have been tens of thousands of views of "Respectful Management of Serious Clinical Adverse Events"1, and along with those views have come comments, suggestions, and anecdotes that made it imperative for the institute to look again at the topic and update it.

Presented in mid-October by author and senior IHI fellow Jim Conway at the American Society for Healthcare Risk Management conference, the biggest differences of note are a new foreword, a section on reimbursement and compensation and one on disclosure of errors that have occurred at another institution.

Conway was also pleased that Stanford University Medical Center shared information on the results of the process it uses to determine if a particular outcome was preventable. The Process for Early Assessment and Resolution of Loss (PEARL) is a seven-day investigation. If deemed preventable, then Stanford estimates compensation and sends an apology and the results of the PEARL investigation to the patient or family members. Since it was implemented, there has been a drop of more than a third in the frequency of claims, with an estimated savings of $3.2 million per fiscal year.

Conway has personal experience dealing with adverse events: He was the executive vice president and chief operating officer of Dana-Farber Cancer Institute for 10 years, his term overarching the period when Betsy Lehman and Maureen Bateman died from medication errors in 1994. He notes that most hospitals think that their disaster plans will work fine for this special kind of disaster, but they may not. Indeed, he says that maybe only a quarter of American hospitals have any kind of plan in place for the aftermath of a serious adverse event. And not responding appropriately can compound the hurt to patients, family, staff involved in an event, and the organization as a whole.

These problems won't just go away if you try to hide from them, Conway says. If you do not handle it well, it will likely get bigger. "Think about how you would want to be treated in the situation," he says.

Among the suggestions the paper outlines:

  1. Have a plan for clinical adverse events.
  2. Have a crisis management team, which should include your media relations person.
  3. Test your crisis management plan and team using the most recent adverse event or near miss.
  4. Ask what worked and what did not for that test.
  5. Concentrate on what happened, not who was responsible.
  6. Make the apology sincere: A stiff apology is "a second insult."
  7. Start root-cause analyses immediately using a trained facilitator.
  8. Create a media action plan before you have a crisis.
  9. Learn from events at other organizations; ask them what they learned.
  10. Ask if such events can happen at your organization.

Conway says he's sure that the input levels will continue, and that in another year or two, this white paper will again be updated. It's an evolving document, not a static one, he says.

The entire white paper is available for download, along with useable checklists, at www.ihi.org.


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

Checklist for crisis management: The patient

Source: Institute for Healthcare Improvement

  • Who is the organizational 24/7 contact person for the patient and family?
  • Has the organization acknowledged the pain, expressed empathy and regret?
  • Are the immediate needs of the patient and family met?
  • Has the patient had a full clinical assessment?
  • Has the organization assessed the personal safety of the patient and family?
  • Has the patient's primary care physician and extended care team been notified?
  • What is being heard from the patient and family?
  • Has the organization apologized, as appropriate?
  • Does the organization understand what the patient and family want said to others about the event?
  • Is the organization providing ongoing support to the patient and family, including reimbursement of out-of-pocket expenses?
  • Is the organization prepared to have open discussions about compensation, if deemed appropriate?
  • Has the family been engaged in the immediate investigation and then invited to participate in the root-cause analysis (RCA) of the event?
  • • Has the organization suppressed all normal PR and other communications to the patient or family that could inflict further pain?