JMIR Publications

ABSTRACT

Background. Preventable medical errors represent a major public health problem. To prevent future errors, improve disclosure, and mitigate malpractice risks, organizations have adopted strategies for transparent communication and emphasized quality improvement through peer review. These principles are incorporated into the Agency for Healthcare Research and Quality (AHRQ) Communication and Optimal Resolution (CANDOR) Toolkit, which facilitates 1) transparent communication, 2) error prevention, and 3) achieving optimal resolution with patients and families. How medical errors should be addressed when they are discovered between facilities—inter-facility medical error discovery (IMED)—is less clear. Without mechanisms for disclosure and feedback on the part of the discovering provider, it is uncertain to what extent IMED is communicated with patients or responsible providers. Further, known barriers to disclosure and reporting one’s own error may not be relevant or replaced by other unknown barriers when considering scenarios of IMED. Methods. We plan a series of studies following an implementation framework. First, we plan a participatory, consensus-building stakeholder panel process to modify CANDOR for application to IMED scenarios. We will then conduct a robust pre-implementation analysis to identify determinants of implementation of the modified process. Using the Consolidated Framework for Implementation Framework as a theoretical framework, we will assess organizational readiness by key informant interviews and individual-level behaviors by a survey. Findings from this analysis will inform the implementation Toolkit that will be developed and pilot tested at two sites. We will measure five implementation outcomes (acceptability, appropriateness, reach, adoption and feasibility) using a combination of key informant interviews and surveys over the pre- and post-implementation phases. Discussion. Providing a communication and resolution strategy applicable to IMED scenarios will help address this current blind spot in the patient safety movement. This work will provide important insights into the potential utility of an implementation Toolkit to improve transparent communication and optimal resolution of IMED scenarios. The natural progression of this work will be to test the Toolkit more broadly, understand the feasibility and barriers of implementation on a broader scale and pilot the implementation in new organizations.