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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)	CARe toolkit
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)	CARe toolkit
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
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
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
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 letters and documentation Letter guidance to craft your own messages to patients and families after an adverse event occurs	CARe toolkit
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
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