Georgia Hospitals Use AHRQ Blood Thinner DVD to Help Reduce Errors, Improve Safety

Patient Safety
June 2009

The 170 member hospitals of the Georgia Hospital Association (GHA) are using a video developed as a result of an AHRQ-sponsored project to help combat medical errors and establish a positive culture conducive to patient safety.

The 55-minute video, Discussing Unanticipated Outcomes and Disclosing Medical Errors, dramatizes right and wrong ways for clinicians and health care personnel to act when something goes wrong in a clinical setting. The video's message—that honesty and respect for patients and families work best in the long run—"continues to resonate with clinicians and other hospital staff," says Vi Naylor, GHA's Executive Vice President.

The video has been used by the GHA's member hospitals for staff training and orientation and in more than a dozen workshops for health care professionals in Georgia and 32 other states. Several health systems have asked to post the video on their internal Web sites for educational purposes. After hospitals, health insurers represent the largest user segment.

GHA has also used the video with its board members, who are hospital CEOs. "We used it to persuade them that they have an opportunity to establish a non-punitive culture in their own hospitals," says Naylor. "The video has tentacles—and it has had a long shelf life," she adds.

The video is also being used in four other countries: Canada, Ireland, Australia, and Saudi Arabia. Requests from outside the United States have come from a variety of sources, including hospitals, a women and children's center, academic institutions, and insurance-affiliated companies.

The video was an early product of the Partnership for Health and Accountability (PHA), an AHRQ-supported collaboration among GHA, its member hospitals, and other community stakeholders. It was written and directed by John Banja, MD, Associate Professor at the Emory University Center for Ethics.

Kathryn McGowan, PHA's Director of Quality and Patient Safety, recalls that the PHA was created in 2000 in response to concerns addressed in the Institute of Medicine's 1999 report, To Err Is Human: Building a Safer Health System. Taking its cue from the report, PHA sought to encourage hospital clinical staff disclosure of lapses, mistakes, and other failures, and to encourage the creation of a non-punitive culture that would focus on fixing what was wrong with the system rather than blaming individuals. The video was conceived as a "how-to" guide for the hospitals and a tool for staff training.

Part I of the video displays three unfortunate scenarios: a clumsy and unsuccessful attempt to hide a mistake that did not result in actual harm; an equally unconvincing attempt to dismiss an error by making light of it; and finally, an example of extreme honesty that could make matters worse. A discussion ensues, moderated by Banja, about whether a clinician who admits error risks lawsuits and loss of insurance coverage. Part II of the video gives examples of empathetic communication, and "what not to say."

The team that developed the video undertook research to demonstrate that "sincerity pays" and that malpractice claims are less likely when errors are acknowledged. On the other hand, patients and families are more likely to sue when they feel that their concerns have been discounted or ignored.

Impact Case Study Identifier: 
AHRQ Product(s): Partnership for Health and Accountability (PHA)
Topics(s): Patient Safety, Medical Errors, Medication Safety
Geographic Location: Georgia
Implementer: Georgia Hospital Association
Date: 06/01/2009

Rask KJ, Schuessler LD, Naylor DV. A statewide voluntary patient safety initiative: The Georgia experience. Joint Commission Journal on Quality and Patient Safety October 2006; (32)10:564-572. (HS110918)

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