What’s New in the Patient Safety World

June 2016

Disclosure and Apology: The CANDOR Toolkit



Our numerous columns on disclosure and apology after medical error (listed below) have stressed that such are not only the right things to do but in the long run help patients and families reach closure and help prevent other similar errors and adverse outcomes. In addition, that approach is now widely accepted as reducing litigation and malpractice settlements.


But the healthcare professions and organizations have historically done a poor job in preparing individuals in providing disclosure and apology. A new toolkit provided by AHRQ, the CANDOR toolkit, provides excellent resources for organizations in this process (AHRQ 2016). CANDOR stands for Communication and Optimal Resolution. The toolkit comes with 8 modules and an implementation guide. The modules come with PowerPoint slides and videos that illustrate key principles and speaker notes to guide the discussions.


The presentations start with identification of a CANDOR event and how to activate your CANDOR Response Team. Ideally, activation of the CANDOR Response Team should begin within 30 minutes after a CANDOR event has been identified. In addition to initiating the fact-finding investigation of the event, a CANDOR Communication Lead should be identified and immediate emotional support to the patient, family, and caregiver should be provided, the latter by activating the Care for Caregiver program. The CANDOR Response Team and/or CANDOR Communication Lead are responsible for the initial communication with the patient and/or family.  The CANDOR Communication Lead coordinates all communications, and ensures that all caregivers are consistent in their communication, i.e., that they stay "on message." Following the initial disclosure conversation, the CANDOR Response Team ensures that a trained communicator establishes ongoing regular communication with the patient and/or family.


As we’ve so often pointed out in the past, we also need to remember that all these unfortunate events also have “second victims”, that is the caregivers involved in the incidents. One of the other key functions of the CANDOR Response Team is assessing the needs of caregivers involved in the harm event and providing initial emotional support and activating the programs your organization hopefully have implemented for providing ongoing support for the caregivers. Details and resources for dealing with the caregivers are provided in Module 6.


Modules 2 and 3 deal with developing the culture your organization needs and preparing your organization for implementation of the CANDOR program.


The first module also describes the Event Investigation and Analysis and timeframes for its optimal initiation and completion, which is further described in detail in Module 4. This is basically the root cause analysis (RCA) plus other considerations and has a checklist to help guide the team(s). Throughout the process the importance of maintaining a “Just Culture” with shared accountability is stressed.


That fourth module also notes it is important to inform the patient, family, and the involved caregivers of the investigation and analysis results. It provides resources to help your organization engage patients and families. It also discusses how to communicate with and involve your organization’s liability carrier. One of the resources is a link to discussions of the University of Michigan's early disclosure and offer program (see our September 2010 What's New in the Patient Safety World column “Followup to Our Disclosure and Apology Tip of the Week”).


Module 5 discusses the response and disclosure and provides some excellent resources and recommendations, such as how to deal with challenging communications. It provides checklists, case scenarios, and videos of both appropriate and inappropriate disclosures to patients.


Module 7 deals with resolution. Resolution in the CANDOR process involves actions associated with addressing the patient, family, and staff expectations. The main objective of resolution in the CANDOR process is to meet the needs and expectations of the patient. It stresses that failure to do this can lead to a loss of trust from the patient. This component of the overall process might lead to a financial settlement, but notes that such settlements might not always lead to resolution of all issues related to the adverse event. Financial recompense is not always the most important need of the patient and/or family. They often want to know that their unfortunate event may lead to implementation of processes that will prevent others from suffering the same consequences. It stresses the importance of the organization taking responsibility and showing legitimate remorse. It also has excellent resources regarding the skills required in properly communicating with multiple parties throughout this phase.


The final module deals with organizational learning and how to ensure sustainability of the CANDOR program and, more importantly, the culture needed to ensure its sustainability.


Overall, the CANDOR toolkit is an outstanding resource that every healthcare organization must take advantage of. Many organizations have had to stumble through handling adverse events and had to learn the hard way. The CANDOR toolkit can help organizations take a very proactive approach to establishing programs that are the right way to do things.



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


Other very valuable resources on disclosure and apology:







AHRQ (Agency for Healthcare Research and Quality). Communication and Optimal Resolution (CANDOR) Toolkit. AHRQ 2016; Rockville, MD http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/introduction.html



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