What’s New in the Patient Safety World

November 2010

IHI: Respectful Management of Serious Clinical Adverse Events



Our June 22, 2010 Patient Safety Tip of the Week “Disclosure and Apology: How to Do It” provided a comprehensive view of the current state of “disclosure and apology” with guidelines on how to approach adverse events with serious outcomes.


Another new resource has become available since that column, IHI’s “Respectful Management of Serious Clinical Adverse Events”. IHI put this white paper together because they were often asked by organizations after a serious adverse event “what do we do?”. The paper contains most of the recommendations we had in our previous column and has several good checklists to help guide organizations in their responses. It also has a very good bibliography.


A few key points in the white paper are worth emphasizing. They highlight the four hallmarks of a strong crisis management response: immediacy, transparency, apology, and accountability. The speed of the response is extremely important. Though you may not have sufficient information immediately to explain all that happened, it is extremely important to the patient and/or family that the response be prompt, visible and honest. Waiting a few days is not acceptable to them. The patient and family have to be the number one focus in such events. That is why every organization should have a process in place for immediate notification of relevant parties and convening of the RCA team after a serious event has occurred. Having a checklist available to aid in that process is very helpful (see our July 24, 2007 Patient Safety Tip of the Week “Serious Incident Response Checklist”) and helps in assigning responsibilities to team members for actions necessary in the investigation. The IHI whitepaper also has another good recommendation: if you have not yet convened your response team for an actual crisis or serious event, do a simulation so that when a real event occurs everyone knows their roles.


A second key point is involvement of top leadership in the whole process. The IHI white paper strongly recommends that the Board and the CEO take highly visible roles, in addition to the clinical leaders of the organization. The CEO and the Board visibility may be very important in conveying to all the sincerity of apology and commitment to transparency.


Above all, a big part of transparency is keeping all parties in the loop. When you commit to a patient/family that you will learn from the event and take steps to make sure events like this don’t happen again, you need to remain engaged with them and update them on your progress on a regular basis. That same commitment should apply to your obligation to your own staff and organization.





Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events. IHI Innovations Series 2010. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2010















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