Spring 2006 the Harvard Hospital Group published the Harvard Consensus Statement: When things go wrong: Responding to adverse events. Click here to download the report.
This group consists of sixteen Harvard Teaching Hospitals.
The paper is organized in three major divisions:
1. The Patient and Family Experience
2. The Caregiver Experience
3. Management of the events.
Each section has three parts:
1. A brief summary of expert consensus about the issue
2. The reason and evidence behind consensus
The Harvard Hospital Group recommends to adopt the following principles:
– full, open and honest disclosure to the patient on the medical error and the damage
– providing genuine follow-up diagnostics and remedial medical care to mitigate the damage
This report is of major importance to the improvement of the position of victims of medical errors and patient safety. Therefore its recommendations should be implemented as soon as possible in Europe and globally.
Tell and Repair principles
based on Harvard Consensus Report(2006) When Things Go wrong: Responding to Adverse Events.
What is the wish of a patient when he/she is damaged by a medical error? Put yourself in his/her place: what would I want if I were hurt by treatment? What is the right thing to do? Guiding principles concerning disclosure directly after the medical error:
1. Report only the facts of the error, what happened.
2. Give reliable information as soon as this is available.
3. Explain which follow-up diagnostics and remedial medical care are recommended.
4. Explain the implications for the prognosis
Open and full disclosure:
1. Tell the patient and family what happened.
2. Take responsibility.
4. Explain that the error will be examined.
5. Explain what will be done to prevent recurrence of the error.
Who and how to communicate:
1. A trusted caregiver should lead the initial communication.
2. The person responsible for next steps in care should lead subsequent communication, possible in presence of person of choice of patient/family.
3. Include primary nurse in communication, if this is the wish of the patient/family.
4. Include member of staff with special communicaton skills.
5. Choose a quiet, neutral area for communication, not the room of the CEO.
1. Conduct follow-up sessions promptly. Apologize in case of delay.
2. Physician who is responsible for care should lead sessions. Involve CEO in case first communication was not successful.
Support and follow-up medical care for the patient, family and caregiver:
1. Take each patient/family concerns serious and be respectful.
2. Maintain the therapeutic relationship, provide appointments. Do not abandon the patient.
3. Put all billing on hold pending analysis of the event.
4. Investigate possible means for providing financial support and provide if necessary financial compensation.
5. Provide if necessary psychological and social support. Provide if necessary psychological counselling for the physician/nurse who caused the error.
After the medical error the following is essential:
- honest and open information : what happened.
- follow-up diagnostics to determine the damage and follow-up remedial medical care to mitigate or repair the damage.
- registration and examination of the error to prevent recurrence and to learn from errors.