New Horizons in Responding to Patients after Adverse Events

Thomas H. Gallagher, MD, Professor of Medicine, University of Washington

The expectation that physicians disclose adverse events and errors to patients has been present for over a decade. Yet most evidence suggests that effective disclosure remains the exception rather than the rule.

In the past, many risk managers, malpractice insurers, and defense attorneys advised physicians to say little or nothing to patients following adverse events or errors out of concern that open disclosure would increase litigation. However, new research suggests that many patients file lawsuits simply to find out what happened and whether any lessons have been learned. About 15 years ago, organizations including the Lexington Veterans Affairs Medical Center and University of Michigan launched programs encouraging open disclosure of adverse events and errors coupled with early, proactive offers of financial compensation when care was unreasonable. Now known as communication-and-resolution programs (CRPs), these initiatives led to reductions in the number of malpractice claims, the costs associated with settling them, and the time to resolution. CRPs implemented at Stanford and the University of Illinois at Chicago also reported positive results.

COPIC Insurance Company, a physician-directed mutual company based in Colorado, adopted a  somewhat different strategy for their CRP, the 3Rs Program. 3Rs (recognize, respond, and resolve) which uses a no-fault approach to provide up to $30,000 reimbursement for patients’ out-of-pocket expenses and lost time, demonstrated success in limiting the likelihood of patients filing a malpractice claim. Notably, because COPIC’s 3Rs program does not provide compensation in response to a patient’s written demand, and because the program does not ask the patient to waive the right to sue, reimbursement payment through the 3Rs program is not reportable to the National Practitioner Data Bank.


While the success of these early communication resolution programs was encouraging, many important questions remained about their widespread applicability. Therefore, in 2010 the federal Agency for Healthcare Research and Quality (AHRQ) funded seven large, statewide demonstration projects focused on patient safety medical liability reform. Physicians Insurance, along with investigators from the University of Washington and Harvard School of Public Health, helped lead the state of Washington’s CRP, the HealthPact Communication and Resolution Program (formerly known as the HealthPact Disclosure and Resolution Program).

The HealthPact program seeks to understand whether the CRP approach that has been successful in closed, selfinsured academic health settings can also work in settings where collaboration is required between multiple insurers or stakeholders. The CRP in Washington, which has been in place for 18 months, involves Providence Regional Medical Center in Everett, Providence St. Mary Medical Center, Providence Sacred Heart Medical Center, the Everett Clinic, the Vancouver Clinic, the Polyclinic, Swedish Medical Center, and Physicians Insurance.

As with any widespread culture change, start-up of the HealthPact CRP has been time-consuming and gradual.  Nonetheless, events are being reported into the system and barriers are being identified and addressed throughout the process.


One critical barrier has been physician concern about whether participating in the CRP might increase the chances of a Medical Quality Assurance Commission review. Addressing this issue, the HealthPact team worked closely with the commission and other key stakeholders, including Physicians Insurance and the Washington State Medical Association, to develop a pilot program of CRP certification. Unanimously approved by the commission’s members, the CRP certification pilot program will include any cases that follow all of the CRP’s recommended elements, as determined by a review committee of patient safety experts, and the commission has agreed not to independently investigate these cases, excluding certain exceptions.

CRP certification represents a major positive development for physicians in Washington State, and indicates an important commitment by all stakeholders to incorporate principles of just culture—which seeks an appropriate balance between individual and system accountability for adverse events—in their work.

Important lessons are also being learned about the critical role that provider support plays after adverse events and errors. Many clinicians experience distress following adverse events and errors, and oftentimes that distress goes unsupported. The unmet emotional needs of providers in these situations can have dramatic consequences for both the health care team and for patients. Fortunately, Physicians Insurance has launched the innovative Peer Support Program for clinicians who have played a role in an adverse event. Clinicians and organization leaders should be aware of this important resource and take advantage of it should the need arise.

Interest in the potential of Communication and Resolution Programs to improve patient safety and reduce malpractice liability continues to accelerate nationally. The success of the demonstration projects has led AHRQ to fund the development of a national CRP toolkit. The toolkit assembles important resources to assist clinicians and institutions in improving the response to medical injury, including state-of-the-art tools for adverse event reporting, analysis, communication and resolution, and care for the caregiver. After piloting, the toolkit resources will be widely available.

Lastly, the HealthPact team is leading the creation of a national collaborative for accountability following medical injury. This coalition will involve all of the leading organizations and experts around communication and resolution programs, including representation from Physicians Insurance, and will promote sharing of best practices, encourage collaborative advocacy for reform to the regulatory environment (such as the National practitioner Data Bank), and provide a vehicle to identify and test innovations in this area.

In summary, the imperative to respond effectively to patients and the health care team following medical injury is moving rapidly from an aspiration to reality, with Physicians Insurance and other Northwest institutions continuing to play a vital role.

Dr. Thomas Gallagher is a general internist and professor at the University of Washington. He is an internationally known patient safety expert and the principal investigator on the AHRQ demonstration project.