What’s New in the Patient Safety World

April 2018



·       More Support for Communication and Resolution Programs

·       Joint Commission and the Second Victim

·       Anesthesia in Parkinson’s

·       Radiologists Get Fatigued, Too



More Support for Communication and Resolution Programs



Disclosure and apology after an adverse medical event where errors contributed is not only the right thing to do, it also likely results in lower liability costs. Our numerous columns on the issue are listed below. Disclosure and apology has evolved into “communication-and-resolution” programs. Such programs communicate with patients when adverse events occur, investigate and explain what happened and, where appropriate, apologize and proactively offer compensation.


Our most recent columns on the issue (our October 2017 What's New in the Patient Safety World column “More Support for Disclosure and Apology” and January 3, 2017 Patient Safety Tip of the Week “What’s Happening to “I’m Sorry”?”) discussed not only successes of such programs but also barriers to successful implementation.


A new study further demonstrates the success of communication and resolution programs (CRP). LeCraw and colleagues compared liability outcomes before and after collaborative communication resolution program implementation at a health system in Tennessee (LeCraw 2018). 43% of events with injury from medical error were resolved with apology alone. Compared to pre-implementation levels, there was a decrease in the average number of new claims filed (1.07 to .36), defense costs ($41,950 to $20,623), settlement costs ($19,480 to $14,228), and total liability costs ($61,430 to $34,851) under collaborative communication resolution program, all measured per 1000 hospital admissions.


No medical error occurred in 65% of adverse events. One percent of adverse events when there was no medical error received compensation.


Moreover, the median time interval to resolve a claim decreased from 17 months to 8 months, a reduction of 53%.


The LeCraw paper describes the CRP process in detail:


At an initial meeting patient or family members tell their story and describe the impact of the event. Family members and/or attorneys are welcome at all meetings and the involved physician or other healthcare provider representatives are encouraged to attend. The primary goal of the initial meeting is to listen and learn about the patient’s questions and concerns. Risk Management (RM) staff describes the resolution process and answers any questions about it.


The reported event is then investigated through the hospital’s usual incident investigation processes. A second meeting takes place between one week and one month after the first. Again, involved physicians may be invited to attend the second meeting. RM reviews the discussion from the first meeting and invites the patient to provide any updates. All non-privileged information about the incident is disclosed to the patient. An effort is made to reconcile the patient’s version of events with the one ascertained through the QI investigation. RM staff answers any remaining questions and agrees to investigate further any unanswered questions.


A patient who is satisfied with the results of the investigation may wish to conclude the meeting without making any requests. The study found that in cases where the patient feels that a medical error took place, the most common requests are for an apology, explanation of the adverse outcome, and some change in hospital policy or operations. If the adverse outcome was the result of medical error, the error is acknowledged, and a sincere apology is given, along with a commitment to change hospital policies to prevent or minimize the chances of recurrence. (The hospital is only able to address those elements involving the hospital, unless the physician agrees to participate.) If compensation is requested by the patient for an adverse outcome due to medical error, the patient is asked to give a breakdown of the amount of compensation requested. RM presents this information to the claims committee, which determines their value for the injury and an amount to offer as compensation.


If the investigation determines no medical error occurred, an explanation is made for the adverse outcome and why the hospital believes the standard of care was not breached. Any request for compensation is denied. RM staff continues to answer the patient’s clarifying questions and may offer to participate in mediation if the patient is not satisfied with the explanation. There is also the potential for a patient who disagrees to initiate a formal legal claim.


When a medical error occurred and compensation is requested, a third meeting is proposed no more than 90 days following initial contact with the patient. Any changes to hospital policy or procedures resulting from the incident are explained to the patient/family with an explanation of how the changes are expected to prevent a recurrence. If the patient accepts the offer of compensation and/or the hospital’s efforts to change policy, a settlement document is signed. If the offer is rejected, RM staff may offer to participate in mediation. If all these efforts are unsuccessful, the patient may still pursue a formal legal claim.



The results achieved in this CRP program are very reassuring. Also, since attorneys were involved in 60% of the above events, the success reported should be encouraging to physicians and hospitals alike. Disclosure and sincere apology go a long way to mend fences when adverse events occur and it’s becoming increasingly clear that full “communication-and-resolution programs” are satisfying to hospitals and patients/families and less costly in the long run.




Some of our prior columns on Disclosure & Apology:

July 24, 2007              Serious Incident Response Checklist

June 16, 2009              Disclosing Errors That Affect Multiple Patients

June 22, 2010              Disclosure and Apology: How to Do It

September 2010          Followup to Our Disclosure and Apology Tip of the Week

November 2010          IHI: Respectful Management of Serious Clinical Adverse Events

April 2012                   Error Disclosure by Surgeons

June 2012                    Oregon Adverse Event Disclosure Guide

December 17, 2013     The Second Victim

July 14, 2015              NPSF’s RCA2 Guidelines

June 2016                    Disclosure and Apology: The CANDOR Toolkit

August 9, 2016           More on the Second Victim

January 3, 2017           What’s Happening to “I’m Sorry”?

October 2017              More Support for Disclosure and Apology




Other very valuable resources on disclosure and apology:








LeCraw FR, Montanera D, Jackson JP, et al. Changes in liability claims, costs, and resolution times following the introduction of a communication-and-resolution program in Tennessee. Journal of Patient Safety and Risk Management 2018; First Published February 14, 2018; 23(1): 13-18







Print “April 2018 More Support for Communication and Resolution Programs






Joint Commission and the Second Victim



The Joint Commission recently published a Quick Safety Issue on supporting second victims (TJC 2018). Our


The Joint Commission document notes that it is estimated that nearly half of health care providers could experience the impact as a second victim at least once in their career and that a 2014 survey of 1,755 physicians outside the U.S. found most physicians had been involved in a serious safety event and most admitted to experiencing second victim effects.


TJC notes most hospitals make the same mistake we made in the early days of patient safety - we often simply made available to second victims professional assistance (employee assistance programs or psychological counselling). Over the years, helping the “second victim” has evolved considerably and such referral for professional help is not a good first line strategy and may even be counterproductive. Support from peers is extremely important if such programs are to be successful.


TJC has the following recommendations:


It goes on to describe components your organization should include if you have, or decide to create, a second victim program:


Our August 2017 What's New in the Patient Safety World column “ROI for a Second Victim Program” focused on Johns Hopkins’ RISE (Resilience In Stressful Events) program and showed how the efforts made were likely very cost effective (Moran 2017). In our August 9, 2016 Patient Safety Tip of the Week “More on the Second Victim” and several other columns we also highlighted the work of Susan Scott and colleagues at the University of Missouri and their MITSS (Medically Induced Trauma Support Services) program.


Second victim programs are essential to any organization that has a good culture of safety. We hope you’ll go to our previous columns on such programs to see the details of what is involved in such programs.



Some of our prior columns on “the second victim”:







TJC (The Joint Commission). Quick Safety Issue 39: Supporting second victims. January 22, 2018




Johns Hopkins’ RISE (Resilience In Stressful Events) program




Moran D, Wu AW, Connors C, et al. Cost-Benefit Analysis of a Support Program for Nursing Staff. Journal of Patient Safety 2017; Post Author Corrections: April 27, 2017




MITSS (Medically Induced Trauma Support Services)







Print “April 2018 Joint Commission and the Second Victim






Anesthesia in Parkinson’s



We don’t tend to focus on one disease in most of our columns. But there is one particular disease in which we see numerous complications in hospitalized patients – Parkinson’s Disease (PD). That is because patients with Parkinson’s are often on medications that are relatively unfamiliar to inpatient staff and are often on dosing frequency regimens that don’t fit well with the routines used in hospitals. In addition, many medications commonly used during hospitalizations may exacerbate symptoms of Parkinson’s. And  clinical aspects of Parkinson’s may predispose to many other adverse events in a hospital, including aspiration, falls, DVT, and other complications related to immobility. Add to that the autonomic dysfunction seen is some Parkinson’s patients (and more so in some Parkinson-look-alikes such as Multiple System Atrophy).


We’ve done several columns, listed below, addressing some of the problems encountered in Parkinson’s patients when inpatients. But we have not yet addressed surgery and anesthesia. A new study has looked at considerations for general anesthesia in Parkinson’s patients (Roberts 2018).


Neurology Advisor (Rodriguez 2018) interviewed on of the authors (SJG Lewis) of that review and he had several important recommendations. First is to continue the usual drug regimen until just before the induction of anesthesia. This is especially critical in patients taking levodopa because of the drug's short half-life. During procedures requiring extended anesthesia, he notes that levodopa can be administered by means of a nasogastric tube. Second, Propofol has been reported to demonstrate dyskinetic effects in individuals with and without movement disorders, including PD, so clinicians should remain aware of the increased risk for Propofol-induced dyskinesia in deciding whether use of Propofol is appropriate or not. Third, PD patients often have sialorrhea caused by impaired swallowing and this may worsen during anesthesia. Glycopyrrolate by mouth and ipratropium spray have been shown to be effective in short-term treatment of sialorrhea.


Several commonly used general anesthetic agents, such as halothane and isoflurane, may influence dopamine transmission. In addition, they note that halothane has been reported to increase cardiac sensitivity to catecholamines and should not be used in patients taking levodopa. Sevoflurane, enflurane, and isoflurane have been suggested as safer alternatives to halothane.


They also stress that the timing of medications pre- and post-surgery, is important and that the PD patient is at risk for neuropsychiatric problems such as psychosis and confusion. If the patient is not likely to receive alimentation by mouth for a few days postoperatively, clinicians will need to think about managing the administration of PD medications. Careful assessment of the PD patient for delirium and agitation is needed and there should be a plan across specialties for prevention and management of delirium and/or hallucinations.


There should also be a clear plan for safe rehabilitation of the patient. 


In our three previous columns on PD inpatients, we’ve stressed that most hospital staff may be unfamiliar not only with medications taken by PD patients (some of which may not even be on the hospital formulary) but also with the unique dosing frequencies needed. The very precise timing of doses is problematic for most hospitals and hospital units because they are used to their own standardized times for medication dispensing and administration. And most anti-Parkinsonian medications are available only in oral form so it is especially problematic when the patient is NPO or is otherwise unable to swallow. Some anti-Parkinson’s formulations are also of the extended-release variety and should not be crushed. Moreover, drugs that worsen extrapyramidal function are often used in the hospital and these may significantly worsen Parkinsonian features. Patients with Parkinson’s also seem to get temporary declines in function when they get a systemic problem, like an infection.


Our June 2015 What's New in the Patient Safety World column “More Risks for Parkinson Inpatients” highlighted some recommendations ISMP (ISMP 2015) made for PD inpatients. Hospitals should expedite medication reconciliation and avoid delays in obtaining nonformulary drugs. They should build computerized alerts to avoid disease-medication interactions or drug-drug interactions. Each PD inpatient should have a unique medication administration schedule and drugs known to worsen PD should be avoided, and sudden cessation of PD meds should be avoided. ISMP noted the importance of both patient and focused staff education and noted neurology consultation is advisable. (We would also note that this is one circumstance where clinical decision support in the form of disease-drug interactions may be very useful.)


The advice in today’s column regarding the anesthesia considerations should be added to the complexities of managing PD inpatients. We’d strongly advise that your neurology staff lead an interdisciplinary team and establish protocols and training for dealing with PD patients who need hospitalization and/or surgery.



Our prior columns on problems related to Parkinson’s Disease patients as inpatients:







Roberts DP, Lewis SJG. Considerations for general anaesthesia in Parkinson's disease. J Clin Neurosci 2018; 48: 34-41




Rodriguez T. Anesthesia in Parkinson Disease Requires Cautious Care. Neurology Advisor 2018; February 09, 2018




ISMP (Institute for Safe Medication Practices). Delayed administration and contraindicated drugs place hospitalized Parkinson’s disease patients at risk. ISMP Medication Safety Alert! Acute Care Edition. March 12, 2015






Print “April 2018 Anesthesia in Parkinson’s






Radiologists Get Fatigued, Too



One of our most frequent topics has been the impact of fatigue on performance and its contribution to medical errors. No one is immune to the detrimental effect of fatigue on performance and it’s no different for radiologists. A recent study (Hanna 2018) used a tool for measuring fatigue and advance eye tracking technology to assess the performance of radiologists (both attendings and residents). The goal was to determine the effect of overnight shifts on performance.


During each session, radiologists viewed 20 bone radiographs consisting of normal and abnormal findings. The Swedish Occupational Fatigue Inventory results demonstrated worsening in all five variables (lack of energy, physical exertion, physical discomfort, lack of motivation, and sleepiness) after overnight shifts. Not surprisingly, participants demonstrated worse diagnostic performance in the fatigued versus not-fatigued state. Viewing time per case was significantly prolonged when the radiologists were fatigued. Mean total fixations generated during the search increased by 60% during fatigued sessions. Mean time to first fixate on bone fractures increased by 34% during fatigued sessions. Moreover, dwell times associated with true- and false-positive decisions increased, whereas those with false negatives decreased. Effects of fatigue were more pronounced in residents.


The authors conclude that further research is needed to address and reverse the impact of such fatigue-related changes. They speculate that environmental changes (eg. lighting) and activity changes (eg. periodic breaks, moving around, etc.) might help mitigate the adverse effects of fatigue on performance.



Some of our other columns on the role of fatigue in Patient Safety:


November 9, 2010      12-Hour Nursing Shifts and Patient Safety

April 26, 2011             Sleeping Air Traffic Controllers: What About Healthcare?

February 2011             Update on 12-hour Nursing Shifts

September 2011          Shiftwork and Patient Safety

November 2011          Restricted Housestaff Work Hours and Patient Handoffs

January 2012               Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 3, 2012           Unintended Consequences of Restricted Housestaff Hours

June 2012                    June 2012 Surgeon Fatigue

November 2012          The Mid-Day Nap

November 13, 2012    The 12-Hour Nursing Shift: More Downsides

July 29, 2014              The 12-Hour Nursing Shift: Debate Continues

October 2014              Another Rap on the 12-Hour Nursing Shift

December 2, 2014       ANA Position Statement on Nurse Fatigue

August 2015               Surgical Resident Duty Reform and Postoperative Outcomes

September 2015          Surgery Previous Night Does Not Impact Attending Surgeon Next Day

September 6, 2016      Napping Debate Rekindled

April 18, 2017             Alarm Response and Nurse Shift Duration

July 11, 2017              The 12-Hour Shift Takes More Hits



Some of our other columns on housestaff workhour restrictions:


December 2008           IOM Report on Resident Work Hours

February 26, 2008       Nightmares: The Hospital at Night

January 2010               Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 2011               No Improvement in Patient Safety: Why Not?

November 2011          Restricted Housestaff Work Hours and Patient Handoffs

January 3, 2012           Unintended Consequences of Restricted Housestaff Hours

June 2012                    Surgeon Fatigue

November 2012          The Mid-Day Nap

December 10, 2013     Better Handoffs, Better Results

April 22, 2014             Impact of Resident Workhour Restrictions

January 2015               More Data on Effect of Resident Workhour Restrictions

August 2015               Surgical Resident Duty Reform and Postoperative Outcomes

September 2015          Surgery Previous Night Does Not Impact Attending Surgeon Next Day

March 2016                 Does the Surgical Resident Hours Study Answer Anything?




Our previous columns on the 12-hour nursing shift:


November 9, 2010      12-Hour Nursing Shifts and Patient Safety

February 2011             Update on 12-hour Nursing Shifts

November 13, 2012    The 12-Hour Nursing Shift: More Downsides

July 29, 2014              The 12-Hour Nursing Shift: Debate Continues

October 2014              Another Rap on the 12-Hour Nursing Shift

December 2, 2014       ANA Position Statement on Nurse Fatigue

September 29, 2015    More on the 12-Hour Nursing Shift

July 11, 2017              The 12-Hour Shift Takes More Hits







Hanna TN,  Zygmont ME, Peterson R, et al. The Effects of Fatigue From Overnight Shifts on Radiology Search Patterns and Diagnostic Performance. J Am Coll Rad 2018; Article in Press January 21, 2018






Print “April 2018 Radiologists Get Fatigued, Too




Print “April 2018 What's New in the Patient Safety World (full column)

Print “April 2018 More Support for Communication and Resolution Programs

Print “April 2018 Joint Commission and the Second Victim

Print “April 2018 Anesthesia in Parkinson’s

Print “April 2018 Radiologists Get Fatigued, Too




Print “PDF version










Tip of the Week Archive


What’s New in the Patient Safety World Archive