When Things Go Wrong - Responding to Adverse Outcomes

Thomas H. Gallagher, MD

Momentum is growing for communcation and resolution programs.

While effective disclosure of adverse events is not a new practice, the momentum for it is growing.

Over the past decade, the case for effective disclosure of adverse events has been gaining ground among various institutions. Oregon and Washington have both developed systems of early disclosure: in Washington, the program is named Communication and Resolution Programs (CRPs); in Oregon, it is known as Early Discussion and Resolution (EDR). For simplification purposes, this article will refer to both as CRPs. CRPs are comprehensive, principled, and systematic, and are meant to enable a more effective response to, and in some cases prevent, adverse events. CRPs emphasize early, transparent communication with patients who have experienced an unexpected outcome, and provide patients who have been harmed by their medical care with an apology and prompt and compassionate explanations for what happened, along with information about how recurrences will be prevented, when possible. For those medical injuries caused by unreasonable care, CRPs also provide patients with proactive offers of financial compensation, without requiring the patient to file a lawsuit. It cannot be overemphasized that a CRP’s central focus is on improving patient safety, and any such compensation is entirely voluntary.


Over the last two years, there has been a concerted effort by health-care advocates to accelerate the adoption of CRPs. The positive messaging surrounding CRPs has garnered support from a wide variety of stakeholders, including health-care institutions and providers, patient advocates, professional-liability insurers, health insurers, regulators, policymakers, and defense attorneys.

Elements within the medical profession have advocated a different response to adverse events for several decades. Much of their early advocacy centered on the importance of disclosing medical errors to patients, and apologizing for those errors. Yet multiple research studies suggested that the medical profession struggled to turn this principle of disclosure into practice. More often than not, patients were not informed about medical errors, and when these conversations did occur, they were handled unskillfully—thereby exacerbating the patient’s suffering. Research studies at this time also documented patients’ strong expectation that medical errors should be handled not only with transparency, but also with learning.

Early communication programs found roots in health-care systems in which a hospital employs and self-insures all providers who practice within its system. The University of Michigan and the Lexington Kentucky Veterans Affairs Hospital were pioneers in the CRP process. They began experimenting with a different approach in 2004, emphasizing transparency but also espousing proactive offers of compensation to patients when the adverse event was due to unreasonable care. As these programs developed, emphasis was increasingly placed on the patient-safety dimension of this work, ensuring that the lessons learned were identified and implemented to reduce the chances that the adverse event would recur.


Over the last decade, this work has evolved into the CRP model that is used today. The key elements of a CRP, and how they represent a change from the traditional model, are listed in the table below.


High-functioning CRPs have several important characteristics. First, they are used for all adverse events, regardless of whether the patient knows the event has occurred, or how likely the patient would be to receive compensation through the traditional legal system. Second, they are comprehensive, with all departments and involved individuals working together to communicate (both with the patient and with involved providers), to investigate the situation, and to determine the proper resolution. Third, they are systematic, with each of these elements being hard-wired and inherently linked to the remaining components.

The current state of CRPs reflects not only the pioneering work done in Michigan and Kentucky, but also outstanding initiatives at the University of Illinois at Chicago and Stanford University, and, more recently, statewide initiatives in Oregon and Massachusetts. Much of this work has been supported through grants from the federal Agency for Healthcare Research and Quality, which funded large-scale planning and demonstration grants and developed an extensive suite of CRP tools known as the CANDOR toolkit (https://tinyurl.com/ydc6loz5l).

The Massachusetts Alliance for Communication and Resolution after Medical Injury (MACRMI) is a stellar example of how CRPs can be beneficial for the patient and the provider alike. MACRMI represents a diverse coalition of stakeholders, including the Massachusetts Bar Association, leading health-care organizations, liability insurers, regulators, health-plan representatives, and others, all coming together to advance CRPs in Massachusetts. The MACRMI website has a lot of great resources, as well as reports presenting data from the MACRMI experience.


While the progress in the CRP field is exciting, several challenges remain. One important barrier relates to institutions’ inconsistent use of the CRP model, using the CRP approach for some cases but not others, or using some elements of the CRP, but not the entire approach, for an individual adverse event. This inconsistent implementation is worrisome, and threatens the long-term success of this work. Metrics and standards are being developed to support institutions in their development of a high-functioning CRP that adheres to this model in a comprehensive, principled, and systematic way.

Another issue that can cause hurdles to arise in the effective use of CRPs is how a health-care institution works with providers who are not employed and/or insured by the facility. CRP success requires that all providers who have a stake in the outcome be represented during the entirety of the process. This ensures that if financial remuneration is offered on behalf of a physician, it is done with the physician’s written consent—which can only be obtained if the physician is aware of and able to participate in the process. (Written consent from the provider is often required prior to monetary compensation being offered under a CRP.)

Some critics also worry that CRPs have the potential to take advantage of patients, especially in cases in which an offer of compensation is made to an unrepresented patient at a lower amount than what the patient deserves, and the patient accepts the offer and signs a release of their right to sue without recognizing that a higher level of compensation was warranted. This, too, is an area where robust metrics and standards, along with rigorous externally conducted research on the nature of financial offers made as part of a CRP, will be important. This concern is one reason why high-functioning CRPs strongly recommend to patients that they obtain legal advice in most cases.

CRPs have the potential to improve the response to adverse events in health care, addressing the patient’s needs for transparency and accountability while promoting disseminated learning and improved quality. For CRPs to achieve their true potential, however, all CRP stakeholders should educate themselves about what CRPs are and how they work, and participate in ongoing conversations about opportunities to improve the process.

Learn More About CRP

Talk to your risk manager or director or Physicians Insurance Claims representative, who can offer valuable resources and discuss with you whether such a program may be right for your practice.Other resources include:

Collaborative for Accountability and Improvement

Agency for Healthcare Research and Quality’s CANDOR toolkit

Oregon Patient Safety Commission Early Discussion and Resolution program


Dr. Gallagher is a general internist, professor, and associate chair in the Department of Medicine at the University of Washington. He is a nationally known patient-safety expert and the 2017 recipient of the John M. Eisenberg Award for Career Achievement in Patient Safety from the National Quality Forum and The Joint Commission. He was a principal investigator in a demonstration project to determine the feasibility of CRP implementation in health-care systems, and formed the Collaborative for Accountability & Improvement, a national coalition of stakeholders dedicated to improving CRP adoption.