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.
Information for patients from the Agency for Healthcare Research and Quality (AHRQ)
Comparing the traditional approach to claims with an honest, principle-driven approach at the University of Michigan using a true case study
Pocket card for clinicians listing steps to take after an adverse event and who to contact for help talking to patients
Chart describing initial steps of CARe process after a significant adverse event occurs
Chart describing CARe process for insurers after internal investigation finds standard of care wasn't met and the patient was significantly harmed
Article in the New England Journal of Medicine describing barriers to physician accountability and suggests penalties for failure to adhere to patient safety practices
Guidance for lawyers representing health care providers during CARe process
How lawyers can best support patients during the CARe process
Best practices to ensure patients have appropriate legal representation during conversations regarding resolution and compensation
Ten recommendations for running a CARe program
Guidance for insurers involved in the CARe process
Ensuring a patient-centered approach during the CARe process
Report prepared by the Harvard Negotiation and Mediation Clinical Program about how to best represent patients participating in CARe
Overview of the CARe process, from the initial patient safety alert to resolution meetings and offers of financial compensation
Study of how physicians disclose errors to patients, and recommendation of standards to promote professional responsibility following errors
Flow chart with examples of what to say and what not to say during conversations with patients and families
Study by the New South Wales Department of Health that aims to improve the experience of staff, patients, and caregivers
Sample data in Excel, from a multi-specialty medical group
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
Summary of defensive medicine and possible remedies, from the Massachusetts Medical Society
Findings underscore the need for organizations to adopt a team disclosure process that includes nurses
Paper in the Suffolk University Law Review that emphasizes the importance of legal representation for patients in disclosure and offer programs
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
Researchers interview health care leaders about barriers to implementation and suggest strategies for overcoming them
Systematic review of interventions that have been used to promote patient involvement in patient safety
Tools from the Agency for Healthcare Research and Quality (AHRQ) to help prioritize concerns and maximize interactions between providers, patients, and families
The Swiss Patient Safety Foundation reviews patients’ attitudes toward engagement in error prevention and efforts to increase patient participation
Research article in BMJ Quality & Safety on factors associated with successful implementation of communication and resolution programs at two Massachusetts hospital systems
Template for tracking adverse events and CARe process status in Excel
Simulation of patient relations staff and doctors talking to a family about the results of their investigation into a delay in diagnosis in the ED
Policies from the National Practitioner Data Bank, Massachusetts Department of Public Health, and Massachusetts Board of Registration in Medicine
Research and foundation for AHRQ's "Guide to Patient and Family Engagement: Enhancing the Quality and Safety of Hospital Care"
Covers the seven aspects of response to adverse events: initial response, truth-telling, apologies, mediation, root cause analysis, compensation, and reporting
Who should be at the initial meeting and what should be discussed
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
Interviews with patients and family members after something went wrong in their medical care
A patient-focused flyer that explains the elements of CARe
Study exploring how surgeons currently disclose medical errors
Tips and sample scripts to help risk managers and patient safety staff broach difficult conversations with providers
Project management template with a suggested schedule for sites implementing a CARe program
Samples, guidelines, and other resources for organizations implementing a new CARe program
Worksheet for organizations adopting their own version of a disclosure and offer program developed by the University of Michigan Health System
Suggested language for health care facilities in resolution conversations with patients where insurer or claims involvement is needed
Sample PowerPoint presentation with an overview of CARe, background information, and data to support the model
Strategies to increase awareness internally and externally of patient safety improvements made in response to a CARe case
Study from the Massachusetts Medical Society that looks at the frequency and impact of defensive medicine across the state
Chapter 224 of the Acts of 2012 included several provisions to facilitate implementation of the CARe model
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
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
A perspective in the New England Journal of Medicine describes reforms that can be implemented without requiring changes in the law
Personal essay by Albert Wu, M.D., M.P.H., on the emotional impact of medical error on clinicians
Guidance for measuring progress through reporting and analyzing metrics
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
How to fill out a report with the NPDB in cases where CARe is used
An example of a CARe case where there were errors; produced for the 2025 CARe Forum
How nontraditional public-policy reforms to medical injury response could lead to safer and higher quality health care
Researchers at University of Michigan Health System review the "open disclosure with offer" model and offer ideas for tailoring it to other settings
Implementation of a disclosure and apology model at Baystate Health, an integrated health care system in western Massachusetts
An example of state legislation supporting open communications and disclosure practices
The Institute for Professionalism and Ethical Practice and CRICO describe the key components of an effective disclosure program
Findings suggest that communication and resolution programs will not lead to higher liability costs when hospitals offer compensation proactively
How to improve communication with patients, from the American College of Obstetricians and Gynecologists
Patients’ perceived willingness to participate in safety-related behaviors and the potential impact of clinicians' encouragement on their willingness levels
The role of punitive sanction in the safety of our health care system
Adding updated fields for CARe cases into the patient safety reporting system
How health care professionals can enhance patient safety by offering a communicative and relational presence with patients and families
Qualitative analysis looking at whether physicians disclose the information patients desire and if their emotional needs are met when an error occurs
An investigation into patients' experiences with CRPs to understand aspects of institutional responses to injury that promoted and impeded reconciliation
Answers to common clinician questions about CARe
Attorneys in Massachusetts that have committed to follow a set of best practices and have attended an educational session about CARe
This literature review confirms that CRPs are effective in responding to patient harms, either improving or having neutral effects on all measured outcomes with no significant downsides
Dr. Kilpatrick at Baystate Health describes his experience with CARe and how to have a successful resolution conversation
Characteristics a health care organization should have in order to implement a successful CARe program
Short description of how to report to the NPBD for communication and resolution programs, published in National Association Medical Staff Services (NAMSS) Gateway
Considerations for before, during and after a resolution conversation
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
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
Survey of American Society for Healthcare Risk Management members on ways to improve reporting and disclosure of medical errors
Guide for health care organizations to improve the practice of respect across the continuum of care
Executive summary describing the development of a roadmap for disclosure, apology and offer programs and recommendations for implementation
Sample process timeline of adverse event
Template for organization's board to show commitment to CARe process
Spreadsheet to keep track of CARe insurer cases
Template with information about patient discussions, who to notify, and how to document
Step-by-step handoff example of a CARe insurer case
Use this letter template as a starting point to craft your messages to patients and families after an internal review is completed
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
Use this letter template as a starting point to craft your messages to patients and families after an adverse event
Use this letter template as a starting point to respond to patients and families after a written inquiry into their care
Use this letter template as a starting point in response to patients and families who are dissatisfied with their care
Sample template for Massachusetts sites required to send response letters to patients who have experienced a Serious Reportable Event (SRE)
Sample template for Massachusetts sites required to send response letters to patients who have experienced a Serious Reportable Event (SRE)
Use this letter template as a starting point to craft your message to patients and families after you've had a resolution conversation
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
Procedure to determine whether an adverse event qualifies for CARe, and to outline the steps that follow
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
Scoping review and approach to appraisal of interventions intended to involve patients in patient safety
Survey of clinicians found that respondents believed formal support should be provided within the institution
Timothy B McDonald, M.D., J.D. presentation at the University of Illinois covers the basics of implementing a disclosure program
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
Nonprofit organization that teaches patients and families about the disclosure movement and how to interact with providers when something goes wrong
Slideshow introducing the PEARL program, it's history, how it works, and data on outcomes and measures
Guide to assist those who want to form an alliance to further CARe in their state or region
Handout for facilities to give to patients and families to explain the CARe program
Research on patients’ and family’ views on how clinicians enact incident disclosure
Article in the New England Journal of Medicine explores disclosure of adverse events that affect many patients
Guide explaining the four steps of "disclosure and offer" programs: Communication, investigation, negotiation and resolution
Survey of more than 3,000 physicians finds that medical errors lead to significant emotional distress; researchers recommend improved organizational resources to support providers
Betsy Lehman Center report on two studies exploring the human and financial cost of medical error in Massachusetts
Ashley B. Yeats, M.D., FACEP, encourages clinicians to think about adverse events from a patient's perspective
JAMA "Special Communication" reviews national trends in medical liability claims and costs, and discusses nontraditional reform approaches
Dr. Alice Coombs presents at the 2021 CARe forum about how to reduce health care disparities and improve outcomes
Study finds that patients often do not formally report when they believe something went wrong
Summary on how medical malpractice insurance works, why premiums change, and what can be done about it
Summary on how medical malpractice insurance works, why premiums change, and what can be done about it
Study finds that U.S. and Canadian physicians' error disclosure attitudes and experiences are similar despite different malpractice environments
BMJ Quality & Safety article offers practical and ethical reasons for including patient and family perspectives in the incident management process
Guide with information about responding to an adverse event, suggested language for talking with patients, and FAQs about disclosure and adverse events
Sigall Bell, M.D. presentation on the benefits of disclosure and barriers to overcome
Case study highlights gaps between patients’ expectations and physicians’ ability for disclosure and apology
