Improving Healthcare Systems’ Disclosures of Large-Scale Adverse Events: A Department of Veterans Affairs Leadership, Policymaker, Research and Stakeholder Partnership

Elwy, A. Rani; Bokhour, Barbara G.; Maguire, Elizabeth M.; Wagner, Todd H.; Asch, Steven M.; Gifford, Allen L.; Gallagher, Thomas H.; Durfee, Janet; Martinello, Richard A.; Schiffner, Susan; Jesse, Robert L.

doi:10.1007/s11606-014-3034-3

Cited by 16 publications

(22 citation statements)

References 7 publications

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“…Fifth, the absence of a patient safety culture was another reason for failing to conduct DPSI [ 32 , 61 ].…”

Section: Resultsmentioning

confidence: 99%

“…The facilitators of DPSI can be summarized in three main points ( Table 4 ). First, the creation of a safe environment for reporting patient safety incidents was found to facilitate DPSI [ 61 , 62 ]. Furthermore, a healthcare professional who observed another healthcare provider disclosing a medical error tended to be more likely to perform DPSI [ 63 ].…”

Section: Resultsmentioning

confidence: 99%

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Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of Patient Safety Incidents: A Systematic Review

Ock

Lim

et al. 2017

J Prev Med Public Health

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ObjectivesWe performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents (DPSI).MethodsWe used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this systematic review and searched PubMed, Scopus, and the Cochrane Library for English articles published between 1990 and 2014. Two authors independently conducted the title screening and abstract review. Ninety-nine articles were selected for full-text reviews. One author extracted the data and another verified them.ResultsThere was considerable variation in the reported frequency of DPSI among medical professionals. The main expected effects of DPSI were decreased intention of the general public to file medical lawsuits and punish medical professionals, increased credibility of medical professionals, increased intention of patients to revisit and recommend physicians or hospitals, higher ratings of quality of care, and alleviation of feelings of guilt among medical professionals. The obstacles to DPSI were fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture. However, the factors facilitating DPSI included the creation of a safe environment for reporting patient safety incidents, as well as guidelines and education for DPSI.ConclusionsThe reported frequency of the experience of the general public with DPSI was somewhat lower than the reported frequency of DPSI among medical professionals. Although we identified various expected effects of DPSI, more empirical evidence from real cases is required.

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“…Fifth, the absence of a patient safety culture was another reason for failing to conduct DPSI [ 32 , 61 ].…”

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of Patient Safety Incidents: A Systematic Review

Ock

Lim

et al. 2017

J Prev Med Public Health

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“…Qualitative studies largely addressed the same topics. Cicognani & Zani (2015) and Elway et al (2014) investigated communication through phases of a crisis via retrospective interviews of crisis communication or emergency response personnel. Herović (2016) and Rissanens (2016) conducted individual in-depth interviews about characteristics of effective communication within the pre-crisis phase.…”

Section: Resultsmentioning

confidence: 99%

Untitled

2021

JICRCR

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The crisis and emergency risk communication (CERC) model is a five-stage theory that merges established public health practices with principles of crisis communication. Although CERC has been regularly applied on the ground, it has been criticized as lacking the coherence and unity necessary to serve as a framework for research. To determine the extent and type of research CERC has generated since its original presentation to the academic community 15 years ago, we conducted a systematic review of research using CERC as a theoretical lens. A total of 4,471 articles in 20 languages were screened, 400 full texts examined, and 19 articles included in the research and theory analysis, of which one tested tenets of the CERC model. We conclude that CERC has rarely been theoretically tested, and we argue that reformulation of the propositions is necessary for empirical support of the model to proceed.

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“…Employees and patients in this study were eager to share their experiences and insights for the design of disclosures to patients in the future. The VA has already acted on some of these lessons and continues to seek out improvements to the process [24]. Our prior work has shown that the design of disclosure communication may impact the ways in which the media represent the events [25].…”

Section: Discussionmentioning

confidence: 99%

Evaluating the implementation of a national disclosure policy for large-scale adverse events in an integrated health care system: identification of gaps and successes

Maguire

Bokhour

Asch

et al. 2016

BMC Health Serv Res

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BackgroundMany healthcare organizations have developed disclosure policies for large-scale adverse events, including the Veterans Health Administration (VA). This study evaluated VA’s national large-scale disclosure policy and identifies gaps and successes in its implementation.MethodsSemi-structured qualitative interviews were conducted with leaders, hospital employees, and patients at nine sites to elicit their perceptions of recent large-scale adverse events notifications and the national disclosure policy. Data were coded using the constructs of the Consolidated Framework for Implementation Research (CFIR).ResultsWe conducted 97 interviews. Insights included how to handle the communication of large-scale disclosures through multiple levels of a large healthcare organization and manage ongoing communications about the event with employees. Of the 5 CFIR constructs and 26 sub-constructs assessed, seven were prominent in interviews. Leaders and employees specifically mentioned key problem areas involving 1) networks and communications during disclosure, 2) organizational culture, 3) engagement of external change agents during disclosure, and 4) a need for reflecting on and evaluating the policy implementation and disclosure itself. Patients shared 5) preferences for personal outreach by phone in place of the current use of certified letters. All interviewees discussed 6) issues with execution and 7) costs of the disclosure.ConclusionsCFIR analysis reveals key problem areas that need to be addresses during disclosure, including: timely communication patterns throughout the organization, establishing a supportive culture prior to implementation, using patient-approved, effective communications strategies during disclosures; providing follow-up support for employees and patients, and sharing lessons learned.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1903-7) contains supplementary material, which is available to authorized users.

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Improving Healthcare Systems’ Disclosures of Large-Scale Adverse Events: A Department of Veterans Affairs Leadership, Policymaker, Research and Stakeholder Partnership

Cited by 16 publications

References 7 publications

Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of Patient Safety Incidents: A Systematic Review

Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of Patient Safety Incidents: A Systematic Review

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Evaluating the implementation of a national disclosure policy for large-scale adverse events in an integrated health care system: identification of gaps and successes

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