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
• Prologue
  Kenneth Sands, Alan Woodward, and Melinda Van Niel.
  • References
• Improving Communication
  • Silence
    Carole Hemmelgarn.
    • Acknowledgements
    • References
  • Reforming the Medical Liability System in Massachusetts: Communication, Apology, and Resolution (CARe)
    Kenneth E.F. Sands, Alan C. Woodward, and Melinda B. Van Niel.
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • Author Affiliations
    • References
  • Planning and Implementing the Patient Advocacy Reporting System® in the Sanford Health System
    James 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.
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • Author Affiliations
    • References
    • Appendix: PARS Program Planning Methods and Procedures Timeline
  • Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery
    David P. Baker, Anthony D. Slonim, and Patrice Weiss.
    • Abstract
    • Introduction
    • Research Study 1
    • Research Study 2
    • Discussion
    • Limitations
    • Conclusion
    • Acknowledgments
    • Author Affiliations
    • References
    • Appendix
• Improving Patient Safety
  • Patient Safety Culture and Medical Liability— Recommendations for Measurement, Analysis, and Interpretation: A Commentary
    Sallie J. Weaver, Jill A. Marsteller, Albert W. Wu, Mohd Nasir Mohd Ismail, and Peter J. Pronovost.
    • Abstract
    • The Intersection of Liability and Patient Safety Culture
    • Recommendations for Exploring the Intersection of Patient Safety Culture with Organizational Approaches to Patient Safety and Liability
    • Conclusion
    • Acknowledgments
    • Author Affiliations
    • References
  • Error Disclosure Training and Organizational Culture
    Jason M. Etchegaray, Thomas H. Gallagher, Sigall K. Bell, William M. Sage, and Eric J. Thomas.
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Limitations
    • Conclusion
    • Acknowledgments
    • Author Affiliations
    • References
  • Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative
    Douglas M. Brock, Andrew A. White, Lauren Lipira, Patricia I. McCotter, Sarah Shannon, and Thomas H. Gallagher.
    • Abstract
    • Introduction
    • Methods
    • Discussion
    • Limitations
    • Conclusion
    • Acknowledgments
    • Author Affiliations
    • References
  • Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned
    Steven Crane, Phillip D Sloane, Nancy C. Elder, Lauren W. Cohen, Natascha Laughtenschlager, and Sheryl Zimmerman.
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Limitations
    • Conclusions
    • Acknowledgments
    • Author Affiliations
    • References
  • Implementing Shared Decision-Making: Barriers and Solution—An Orthopedic Case Study
    Shawn 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.
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Limitations
    • Conclusions
    • Acknowledgments
    • Author Affiliations
    • References
  • Transitional Care Medication Safety: Stakeholders’ Perspectives
    Cynthia F. Corbett, Alice E. Dupler, Suzanna Smith, E’lise M. Balogh, and Cory R. Bolkan.
    • Abstract
    • Introduction
    • Methods
    • Discussion
    • Limitations and Strengths
    • Conclusion
    • Acknowledgments
    • Authors' Affiliations
    • References
  • Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home
    Joshua J. Neumiller, Stephen M. Setter, Allison M. White, Cynthia F. Corbett, Douglas L. Weeks, Kenn B. Daratha, and Jeffrey B. Collins.
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • Author Affiliations
    • References

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.