Responding to patient safety incidents: the “seven pillars”
- T B McDonald1,2,
- L A Helmchen3,4,
- K M Smith1,2,
- N Centomani5,
- A Gunderson1,
- D Mayer1,2,
- W H Chamberlin5
- 1Department of Medical Education, Department of Medicine, Department of Anesthesiology & Pediatrics, Department of Undergraduate Medical Education and Anesthesiology, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
- 2Institute for Patient Safety Excellence, University of Illinois at Chicago, Chicago, Illinois, USA
- 3Department of Health Policy Administration, School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
- 4Institute of Government and Public Affairs, University of Illinois, Chicago, Illinois, USA
- 5Department of Medicine, and Medical Center Administration, Department of Safety and Risk Management, University of Illinois Medical Center at Chicago, Chicago, Illinois, USA
- Correspondence to Dr Timothy B McDonald, Safety & Risk Management (MC 805), 174 West Taylor Street, Suite 1160, Chicago, IL 60612-7233 USA;
- Accepted 20 April 2009
- Published Online First 1 March 2010
Background Although acknowledged to be an ethical imperative for providers, disclosure following patient safety incidents remains the exception. The appropriate response to a patient safety incident and the disclosure of medical errors are neither easy nor obvious. An inadequate response to patient harm or an inappropriate disclosure may frustrate practitioners, dent their professional reputation, and alienate patients.
Methods The authors have presented a descriptive study on the comprehensive process for responding to patient safety incidents, including the disclosure of medical errors adopted at a large, urban tertiary care centre in the United States.
Results In the first two years post-implementation, the “seven pillars” process has led to more than 2,000 incident reports annually, prompted more than 100 investigations with root cause analysis, translated into close to 200 system improvements and served as the foundation of almost 106 disclosure conversations and 20 full disclosures of inappropriate or unreasonable care causing harm to patients.
Conclusions Adopting a policy of transparency represents a major shift in organisational focus and may take several years to implement. In our experience, the ability to rapidly learn from, respond to, and modify practices based on investigation to improve the safety and quality of patient care is grounded in transparency.
- Patient safety incident
- medical errors
- risk management
- patient safety
- adverse event
- significant event analysis
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.