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In October 2009, AHRQ launched the Patient Safety and Medical Liability (PSML) Initiative to address four goals: (1) putting patient safety first by reducing preventable injuries, (2) fostering better communication between doctors and patients, (3) ensuring fair and timely compensation for medical injuries while reducing malpractice litigation, and (4) reducing liability premiums. Under the PSML initiative, AHRQ funded 13 planning grants and 7 demonstration grants; the goal was to help States and health systems seek comprehensive solutions that improve patient safety and address the underlying causes of the malpractice problem. This publication, Advances in Patient Safety and Medical Liability, presents contributions and findings from the AHRQ-funded projects. In addition to a prologue, the volume includes two commentaries and nine papers, organized into two primary themes: improving communication and improving patient safety.
Contents
- Preface
- Acknowledgements
- PrologueKenneth Sands, Alan Woodward, and Melinda Van Niel.
- Improving Communication
- SilenceCarole Hemmelgarn.
- Reforming the Medical Liability System in Massachusetts: Communication, Apology, and Resolution (CARe)Kenneth E.F. Sands, Alan C. Woodward, and Melinda B. Van Niel.
- Planning and Implementing the Patient Advocacy Reporting System® in the Sanford Health SystemJames W. Pichert, Wendell W. Hoffman, David Danielson, Cindy Baldwin, Craig Uthe, Meghan Goldammer, Thomas F. Catron, Sue Garey, Jan Karrass, Peggy Westlake, Rhonda Ketterling, William O. Cooper, and Gerald B. Hickson.
- Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and DeliveryDavid P. Baker, Anthony D. Slonim, and Patrice Weiss.
- Silence
- Improving Patient Safety
- Patient Safety Culture and Medical Liability— Recommendations for Measurement, Analysis, and Interpretation: A CommentarySallie J. Weaver, Jill A. Marsteller, Albert W. Wu, Mohd Nasir Mohd Ismail, and Peter J. Pronovost.
- Error Disclosure Training and Organizational CultureJason M. Etchegaray, Thomas H. Gallagher, Sigall K. Bell, William M. Sage, and Eric J. Thomas.
- Applying a Novel Organization Change Scale in a Multisite Patient Safety InitiativeDouglas M. Brock, Andrew A. White, Lauren Lipira, Patricia I. McCotter, Sarah Shannon, and Thomas H. Gallagher.
- Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons LearnedSteven Crane, Phillip D Sloane, Nancy C. Elder, Lauren W. Cohen, Natascha Laughtenschlager, and Sheryl Zimmerman.
- Implementing Shared Decision-Making: Barriers and Solution—An Orthopedic Case StudyShawn L. Mincer, Michael J. Lee, Richard J. Bransford, Saint Adeogba, Karen L. Posner, Lynne S. Robins, Pornsak Chandanabhumma, Michelle S. Lam, Aaron S. Azose, and Karen B. Domino.
- Transitional Care Medication Safety: Stakeholders’ PerspectivesCynthia F. Corbett, Alice E. Dupler, Suzanna Smith, E’lise M. Balogh, and Cory R. Bolkan.
- Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to HomeJoshua J. Neumiller, Stephen M. Setter, Allison M. White, Cynthia F. Corbett, Douglas L. Weeks, Kenn B. Daratha, and Jeffrey B. Collins.
- Patient Safety Culture and Medical Liability— Recommendations for Measurement, Analysis, and Interpretation: A Commentary
Suggested citation:
Advances in Patient Safety and Medical Liability. Battles J, Azam I, Grady M, and Reback K, Eds. AHRQ Publication No. 17-0017-EF. Rockville, MD: Agency for Healthcare Research and Quality; August 2017.
The opinions presented in this publication are those of the authors and do not necessarily represent the position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
- NLM CatalogRelated NLM Catalog Entries
- Progress at the Intersection of Patient Safety and Medical Liability: Insights from the AHRQ Patient Safety and Medical Liability Demonstration Program.[Health Serv Res. 2016]Progress at the Intersection of Patient Safety and Medical Liability: Insights from the AHRQ Patient Safety and Medical Liability Demonstration Program.Ridgely MS, Greenberg MD, Pillen MB, Bell J. Health Serv Res. 2016 Dec; 51 Suppl 3(Suppl 3):2414-2430.
- Administrative compensation for medical injuries: lessons from three foreign systems.[Issue Brief (Commonw Fund). 2011]Administrative compensation for medical injuries: lessons from three foreign systems.Mello MM, Kachalia A, Studdert DM. Issue Brief (Commonw Fund). 2011 Jul; 14:1-18.
- How policy makers can smooth the way for communication-and- resolution programs.[Health Aff (Millwood). 2014]How policy makers can smooth the way for communication-and- resolution programs.Sage WM, Gallagher TH, Armstrong S, Cohn JS, McDonald T, Gale J, Woodward AC, Mello MM. Health Aff (Millwood). 2014 Jan; 33(1):11-9.
- Review Medical malpractice reform measures and their effects.[Chest. 2013]Review Medical malpractice reform measures and their effects.Leflar RB. Chest. 2013 Jul; 144(1):306-318.
- Review Linking health information technology to patient safety and quality outcomes: a bibliometric analysis and review.[Inform Health Soc Care. 2013]Review Linking health information technology to patient safety and quality outcomes: a bibliometric analysis and review.Whipple EC, Dixon BE, McGowan JJ. Inform Health Soc Care. 2013 Jan; 38(1):1-14. Epub 2012 Jun 1.
- Advances in Patient Safety and Medical LiabilityAdvances in Patient Safety and Medical Liability
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