PULSE: Respectful Management of Serious Clinical Adverse Events

November/December 2010


??The Institute for Healthcare Improvement has released a new white paper in the IHI Innovation Series titled Respectful Management of Serious Clinical Adverse Events.

The paper is available on the IHI website for free download at www.ihi.org/IHI/Results/WhitePapers. The paper was released and presented at the National Association for Healthcare Quality (NAHQ) 35th Annual Educational Conference in Kansas City, Missouri, on October 1, 2010.

The paper addresses the importance of having a tested crisis management plan in place to respond to the clinical adverse events, and provides specific guidance and tools for developing such a plan.

The risks of not responding to these events in a timely and effective manner are significant. They include the loss of trust, absence of healing, no learning and improvement, sending mixed messages about what is really important to the organization, increased likelihood of regulatory action or lawsuits, and challenges by the media.

IHI developed the white paper in response to numerous requests from organizations seeking assistance in the aftermath of an adverse event. The most striking aspect of these requests is that the organization’s response is often being built from scratch, in a reactive mode, rather than from an existing clinical crisis management plan. To respond effectively to these types of requests, IHI draws on patient- and family-centered care, patient safety, crisis management, and disaster planning, and on the experiences of health care organizations that have attempted to manage such crises in a respectful and effective manner. This IHI white paper:

  • encourages and helps every organization to develop a clinical crisis management plan before they need to use it;
  • provides an approach to integrate this plan into the organizational culture of quality and safety, with a particular focus on patient- and family-centered care and fair and just treatment for staff; and
  • provides organizations with a concise and practical resource to inform their efforts when a serious adverse event occurs in the absence of an organizational clinical crisis management plan or culture of quality and safety.