The list below includes guidelines, tools, research, and other resources related to communication and resolution programs. Download the implementation guide for links to the most commonly used resources from the Betsy Lehman Center. Find videos and presentations from past events on the CARe forums page.

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Resource

Category

20 things patients can do to help prevent medical errors

Information for patients from the Agency for Healthcare Research and Quality (AHRQ)

For patients and families

30-day SRE sample letter

Sample template for Massachusetts sites required to send response letters to patients who have experienced a Serious Reportable Event (SRE)

Sample letters

7-day SRE sample letter

Sample template for Massachusetts sites required to send response letters to patients who have experienced a Serious Reportable Event (SRE)

Sample letters

A better approach to medical malpractice claims? The University of Michigan experience

Comparing the traditional approach to claims with an honest, principle-driven approach at the University of Michigan using a true case study

Research and data

Adverse event procedure card

Pocket card for clinicians listing steps to take after an adverse event and who to contact for help talking to patients

CARe toolkit

Algorithm #1: Initial steps and case filter

Chart describing initial steps of CARe process after a significant adverse event occurs

Implementation guides

Algorithm #2: Insurer case protocol

Chart describing CARe process for insurers after internal investigation finds standard of care wasn't met and the patient was significantly harmed

Implementation guides

Balancing “no blame” with accountability in patient safety

Article in the New England Journal of Medicine describing barriers to physician accountability and suggests penalties for failure to adhere to patient safety practices

Research and data

Best practices for attorneys representing health care providers using CARe

Guidance for lawyers representing health care providers during CARe process

Best practices • For attorneys

Best practices for attorneys representing patients using CARe

How lawyers can best support patients during the CARe process

Best practices • For attorneys

Best practices for CARe facilities regarding patient representation

Best practices to ensure patients have appropriate legal representation during conversations regarding resolution and compensation

Best practices

Best practices for CARe programs

Ten recommendations for running a CARe program.

Best practices

Best practices for insurers involved in CARe

Guidance for insurers involved in the CARe process

Best practices

Best practices for interfacing with patients during CARe

Ensuring a patient-centered approach during the CARe process

Best practices

Best practices for patient representation in the CARe program and other CRPs

Report prepared by the Harvard Negotiation and Mediation Clinical Program about how to best represent patients participating in CARe

Best practices • Research and data

CARe timeline

Overview of the CARe process, from the initial patient safety alert to resolution meetings and offers of financial compensation

Implementation guides

Choosing your words carefully: How physicians would disclose harmful medical errors to patients

Study of how physicians disclose errors to patients, and recommendation of standards to promote professional responsibility following errors

For clinicians • Research and data

Clinician CARe communication algorithm

Flow chart with examples of what to say and what not to say during conversations with patients and families

For clinicians

Codesigning as a discursive practice in emergency health services: The architecture of deliberation

Study by the New South Wales Department of Health that aims to improve the experience of staff, patients, and caregivers

Research and data

Data from the Reliant CARe program 2004-2012

Sample data in Excel, from a multi-specialty medical group

Research and data

Data snapshot from the Harvard School of Public Health (2013-2014)

Michelle Mello, J.D., Ph.D., and Lena Kuznetsov, M.A., present CARe data from Beth Israel Deaconess Medical Center, Boston Medical Center, Brigham and Women's and Brigham-Faulkner

Research and data

Defensive medicine: A synopsis

Summary of defensive medicine and possible remedies, from the Massachusetts Medical Society

Research and data

Disclosing errors to patients: Perspectives of registered nurses

Findings underscore the need for organizations to adopt a team disclosure process that includes nurses

Best practices • For clinicians

Disclosure and offer at twenty-five: Time to adopt policies to promote fairly negotiated compensation

Paper in the Suffolk University Law Review that emphasizes the importance of legal representation for patients in disclosure and offer programs

Best practices

Disclosure and risk management in HSCT

Presentation by Jeffrey Driver, J.D., M.B.A. and Shirley Johnson, R.N., M.B.A., on the PEARL program at Stanford Health Care

Articles and presentations

Disclosure, apology, and offer programs: Stakeholders’ views of barriers to and strategies for broad implementation

Researchers interview health care leaders about barriers to implementation and suggest strategies for overcoming them

Research and data

Effectiveness of interventions designed to promote patient involvement to enhance safety

Systematic review of interventions that have been used to promote patient involvement in patient safety

Research and data

Engaging patients and families in their health care

Tools from the Agency for Healthcare Research and Quality (AHRQ) to help prioritize concerns and maximize interactions between providers, patients, and families

Best practices • For clinicians

Engaging patients as vigilant partners in safety: A systematic review

The Swiss Patient Safety Foundation reviews patients’ attitudes toward engagement in error prevention and efforts to increase patient participation

Research and data

Ensuring successful implementation of communication and resolution programs

Research article in BMJ Quality & Safety on factors associated with successful implementation of communication and resolution programs at two Massachusetts hospital systems

Research and data

Event tracker

Template for tracking adverse events and CARe process status in Excel

CARe toolkit

Federal and state statutes relative to reporting of malpractice claims and adverse events

Policies from the National Practitioner Data Bank, Massachusetts Department of Public Health, and Massachusetts Board of Registration in Medicine

Laws and regulations

Guide to insurer referral conversations

Suggested language for insurers talking to patients, whether they believe the standard of care was not met or if they are not sure

Best practices

Guide to patient and family engagement: Environmental scan report

Research and foundation for AHRQ's "Guide to Patient and Family Engagement: Enhancing the Quality and Safety of Hospital Care"

For clinicians • Research and data

Guidelines for handling medical adverse events: Enhancing safety through candid communication

Covers the seven aspects of response to adverse events: initial response, truth-telling, apologies, mediation, root cause analysis, compensation, and reporting

For clinicians

Guidelines for initial CARe meeting

Who should be at the initial meeting and what should be discussed

Implementation guides

Guiding principles for CARe Support

CARe Support, also known as service recovery, aims to cover a portion of the cost incurred by the patient or family members as a result of the adverse event

Implementation guides

Guilty, afraid, and alone — Struggling with medical error

Interviews with patients and family members after something went wrong in their medical care

Research and data

Handout for patients

A patient-focused flyer that explains the elements of CARe

For patients and families

How surgeons disclose medical errors to patients: A study using standardized patients

Study exploring how surgeons currently disclose medical errors

Best practices • Research and data

How to talk to an involved provider about a CARe case

Tips and sample scripts to help risk managers and patient safety staff broach difficult conversations with providers

Implementation guides

Implementation Gantt chart

Project management template with a suggested schedule for sites implementing a CARe program

CARe toolkit

Implementation guide

Samples, guidelines, and other resources for organizations implementing a new CARe program

Implementation guides

Implementing your version of the Michigan Model

Worksheet for organizations adopting their own version of a disclosure and offer program developed by the University of Michigan Health System

Implementation guides

Introductory presentation about CARe

Sample PowerPoint presentation with an overview of CARe, background information, and data to support the model

CARe toolkit

Inventory of patient safety improvement spread strategies

Strategies to increase awareness internally and externally of patient safety improvements made in response to a CARe case

Best practices • Implementation guides

Investigation of defensive medicine

Study from the Massachusetts Medical Society that looks at the frequency and impact of defensive medicine across the state

Research and data

Key liability provisions in the 2012 Massachusetts Payment Reform Legislation

Chapter 224 of the Acts of 2012 included several provisions to facilitate implementation of the CARe model

Laws and regulations

Labor and delivery error case simulation

Three videos depicting the first resolution meeting, the initial conversation between the insurer and patient/family, and the follow-up conversation after an investigation; recorded at the 2018 CARe Forum

Simulations and case studies

Liability claims and costs before and after implementation of a medical error disclosure program

Study finds a program of full disclosure of medical errors did not increase total claims and liability costs at the University of Michigan Health System

Research and data

Malpractice reform — Opportunities for leadership by health care institutions and liability insurers

A perspective in the New England Journal of Medicine describes reforms that can be implemented without requiring changes in the law

Articles and presentations

Medical error: The second victim

Personal essay by Albert Wu, M.D., M.P.H., on the emotional impact of medical error on clinicians

Articles and presentations • For clinicians

Metrics guidance

Guidance for measuring progress through reporting and analyzing metrics

CARe toolkit • Research and data

Missed radiology finding case simulation

Four videos depicting the first phone call alerting patient safety, the disclosure conversation between the physician and patient, the first conversation with patient safety and the final resolution conversation; produced for the 2023 CARe Forum

Simulations and case studies

National Practitioner Data Bank form

How to fill out a report with the NPDB in cases where CARe is used

Implementation guides

New directions in medical liability reform

How nontraditional public-policy reforms to medical injury response could lead to safer and higher quality health care

Articles and presentations

Nurturing a culture of patient safety and achieving lower malpractice risk through disclosure: Lessons learned and future directions

Researchers at University of Michigan Health System review the "open disclosure with offer" model and offer ideas for tailoring it to other settings

Research and data

One system’s journey in creating a disclosure and apology program

Implementation of a disclosure and apology model at Baystate Health, an integrated health care system in western Massachusetts

Articles and presentations

Oregon senate bill 483: Resolution of adverse health care incidents

An example of state legislation supporting open communications and disclosure practices

Laws and regulations

Organizational building blocks toward an effective practice of disclosure

The Institute for Professionalism and Ethical Practice and CRICO describe the key components of an effective disclosure program

Articles and presentations

Outcomes in two Massachusetts hospital systems give reason for optimism about communication and resolution programs

Findings suggest that communication and resolution programs will not lead to higher liability costs when hospitals offer compensation proactively

Research and data

Partnering with patients to improve safety

How to improve communication with patients, from the American College of Obstetricians and Gynecologists

Articles and presentations

Patient involvement in patient safety: How willing are patients to participate?

Patients’ perceived willingness to participate in safety-related behaviors and the potential impact of clinicians' encouragement on their willingness levels

Research and data

Patient safety and the “just culture”: A primer for health care executives

The role of punitive sanction in the safety of our health care system

Articles and presentations

Patient safety reporting system change suggestions

Adding updated fields for CARe cases into the patient safety reporting system

CARe toolkit

Patient safety: A consumer's perspective

How health care professionals can enhance patient safety by offering a communicative and relational presence with patients and families

Articles and presentations • Research and data

Patients’ and physicians’ attitudes regarding the disclosure of medical errors

Qualitative analysis looking at whether physicians disclose the information patients desire and if their emotional needs are met when an error occurs

Research and data

Patients’ experiences with communication and resolution programs after medical injury

An investigation into patients' experiences with CRPs to understand aspects of institutional responses to injury that promoted and impeded reconciliation

Research and data

Physician FAQs

Answers to common clinician questions about CARe

For clinicians

Printable attorney's list

Attorneys in Massachusetts that have committed to follow a set of best practices and have attended an educational session about CARe

For patients and families

Provider testimonial: What to expect during the CARe process

Dr. Kilpatrick at Baystate Health describes his experience with CARe and how to have a successful resolution conversation

For clinicians

Readiness checklist

Characteristics a health care organization should have in order to implement a successful CARe program

CARe toolkit

Reporting to the National Practitioner Data Bank

Short description of how to report to the NPBD for communication and resolution programs, published in National Association Medical Staff Services (NAMSS) Gateway

Implementation guides

Resolution conversation checklist

Considerations for before, during and after a resolution conversation

CARe toolkit

Alleged delay in diagnosis in the ED case simulation

Patient relations staff and doctors sit down with family members to explain the results of their investigation

Simulations and case studies

Respectful management of serious clinical adverse events

White paper introducing an approach to two processes: (1) proactive plan for managing serious adverse events, and (2) reactive emergency response of an organization that has no such plan.

Articles and presentations

Responding to patient safety incidents: The “seven pillars”

The University of Illinois Medical Center at Chicago's comprehensive process for responding to patient safety incidents, including full disclosure of harm-causing unreasonable care

Articles and presentations • Research and data

Risk managers' attitudes and experiences regarding patient safety and error disclosure

Survey of American Society for Healthcare Risk Management members on ways to improve reporting and disclosure of medical errors

Research and data

Roadmap for advancing the practice of respect in health care

Guide for health care organizations to improve the practice of respect across the continuum of care

Best practices • Research and data

Roadmap for transforming medical liability and improving patient safety in Massachusetts

Executive summary describing the development of a roadmap for disclosure, apology and offer programs and recommendations for implementation

Best practices • Research and data

Sample adverse event process

Sample process timeline of adverse event

CARe toolkit

Sample board resolution

Template for organization's board to show commitment to CARe process

CARe toolkit

Sample CARe insurer case tracking spreadsheet

Spreadsheet to keep track of CARe insurer cases

Best practices

Sample communication policy

Template with information about patient discussions, who to notify, and how to document

CARe toolkit

Sample letter: After review is completed

Use this letter template as a starting point to craft your messages to patients and families after an internal review is completed

Sample letters

Sample letter: Grievance response or disclosure follow-up

Use this letter template as a starting point to respond to patients and families after a grievance or as a follow-up to a disclosure

Sample letters

Sample letter: Required event notification

Use this letter template as a starting point to craft your messages to patients and families after an adverse event

Sample letters

Sample letter: Responding to written inquiry (when meeting/discussion could not occur)

Use this letter template as a starting point to respond to patients and families after a written inquiry into their care

Sample letters

Sample letter: Response to dissatisfaction in care

Use this letter template as a starting point in response to patients and families who are dissatisfied with their care

Sample letters

Sample letter: Summarizing resolution conversation

Use this letter template as a starting point to craft your message to patients and families after you've had a resolution conversation

Sample letters

Sample letter: Unable to reach patient

Use this letter template as a starting point to reach out to patients and families when you have been unable to reach them by phone.

Sample letters

Sample procedure for determination and use

Procedure to determine whether an adverse event qualifies for CARe, and to outline the steps that follow

CARe toolkit

Sample tracked event criteria

List of criteria for cases that need closer inspection with a CARe lens; not all will become CARe insurer cases, but they should be flagged

CARe toolkit

Scoping review and approach to appraisal of interventions intended to involve patients in patient safety

Literature review of 745 reports about the involvement of patients in patient safety efforts

Research and data

Second victim response teams: Institutional design strategies to care for our own

Survey of clinicians found that respondents believed formal support should be provided within the institution

Research and data

Setting up a successful patient disclosure program

Timothy B McDonald, M.D., J.D. presentation at the University of Illinois covers the basics of implementing a disclosure program

Articles and presentations

Simulation of conversation with clinician after error was made

A risk manager talks to the provider after a medication error to let them know about the error and how they will handle it using the CARe process

Simulations and case studies

Sorry Works!

Nonprofit organization that teaches patients and families about the disclosure movement and how to interact with providers when something goes wrong

For patients and families

Stanford's Process for Early Assessment and Resolution of Loss (PEARL) program

Slideshow introducing the PEARL program, it's history, how it works, and data on outcomes and measures

Articles and presentations • Research and data

Starting a state or regional alliance to support a communication, apology, and resolution initiative

Guide to assist those who want to form an alliance to further CARe in their state or region

Implementation guides

Template: Information for patients after a medical injury

Handout for facilities to give to patients and families to explain the CARe program

CARe toolkit • For patients and families

The “100 patient stories” qualitative study

Research on patients’ and family’ views on how clinicians enact incident disclosure

Research and data

The disclosure dilemma: Large-scale adverse events

Article in the New England Journal of Medicine explores disclosure of adverse events that affect many patients

Research and data

The disclosure-and-offer model: Understanding the basics

Guide explaining the four steps of "disclosure and offer" programs: Communication, investigation, negotiation and resolution

Implementation guides

The emotional impact of medical errors on practicing physicians

Survey of more than 3,000 physicians finds that medical errors lead to significant emotional distress; researchers recommend improved organizational resources to support providers

Research and data

The Financial and Human Cost of Medical Error ... and How Massachusetts Can Lead the Way on Patient Safety

Betsy Lehman Center report on two studies exploring the human and financial cost of medical error in Massachusetts

Research and data

The human connection: Looking at adverse events from a patient-centered perspective

Ashley B. Yeats, M.D., FACEP, encourages clinicians to think about adverse events from a patient's perspective

Articles and presentations

The medical liability climate and prospects for reform

JAMA "Special Communication" reviews national trends in medical liability claims and costs, and discusses nontraditional reform approaches

Research and data

Think again: Everyone doesn't think the same

Dr. Alice Coombs presents at the 2021 CARe forum about how to reduce health care disparities and improve outcomes

Articles and presentations

Toward patient-centered cancer care: Patient perceptions of problematic events, impact, and response

Study finds that patients often do not formally report when they believe something went wrong

Research and data

Understanding medical malpractice insurance: 2006 primer and 2011 update

Summary on how medical malpractice insurance works, why premiums change, and what can be done about it

For clinicians • Research and data

US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients

Study finds that U.S. and Canadian physicians' error disclosure attitudes and experiences are similar despite different malpractice environments

Research and data

What do patients and relatives know about problems and failures in care?

BMJ Quality & Safety article offers practical and ethical reasons for including patient and family perspectives in the incident management process

Research and data

When things go wrong in the ambulatory setting

Guide with information about responding to an adverse event, suggested language for talking with patients, and FAQs about disclosure and adverse events

Implementation guides

When things go wrong: Disclosure of medical error

Sigall Bell, M.D. presentation on the benefits of disclosure and barriers to overcome

Articles and presentations

Wrong-site surgery case study

Case study highlights gaps between patients’ expectations and physicians’ ability for disclosure and apology

Simulations and case studies