Advances in Patient Safety and Medical Liability

In October 2009, AHRQ launched the Patient Safety and Medical Liability (PSML) Initiative to address four goals: (1) putting patient safety first by reducing preventable injuries, (2) fostering better communication between doctors and patients, (3) ensuring fair and timely compensation for medical injuries while reducing malpractice litigation, and (4) reducing liability premiums. Under the PSML initiative, AHRQ funded 13 planning grants and 7 demonstration grants; the goal was to help States and health systems seek comprehensive solutions that improve patient safety and address the underlying causes of the malpractice problem. This publication, Advances in Patient Safety and Medical Liability, presents contributions and findings from the AHRQ-funded projects. In addition to a prologue, the volume includes two commentaries and nine papers, organized into two primary themes: improving communication and improving patient safety.

James Battles, PhD
Irim Azam, MPH
Mary Grady, BS
Kathryn Reback, JD, MSN

Agency for Healthcare Research and Quality
Rockville, MD



Kenneth Sands, Alan Woodward, and Melinda Van Niel

Improving Communication

Commentary: Silence
Carole Hemmelgarn

Reforming the Medical Liability System in Massachusetts: Communication, Apology, and Resolution (CARe)
Kenneth E.F. Sands, Alan C. Woodward, and Melinda B. Van Niel

Planning and Implementing the Patient Advocacy Reporting System® in the Sanford Health System
James W. Pichert, Wendell W. Hoffman, David Danielson, Cindy Baldwin, Craig Uthe, Meghan Goldammer, Thomas F. Catron, Sue Garey, Jan Karrass, Peggy Westlake, Rhonda Ketterling, William O. Cooper, and Gerald B. Hickson

Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery
David P. Baker, Anthony D. Slonim, and Patrice Weiss

Improving Patient Safety

Commentary: Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation
Sallie J. Weaver, Jill A. Marsteller, Albert W. Wu, Mohd Nasir Mohd Ismail, and Peter J. Pronovost

Error Disclosure Training and Organizational Culture
Jason M. Etchegaray, Thomas H. Gallagher, Sigall K. Bell, William M. Sage, and Eric J. Thomas

Applying a Novel Organizational Change Scale in a Multisite Patient Safety Initiative
Douglas M. Brock, Andrew A. White, Lauren Lipira, Patricia I. McCotter, Sarah Shannon, and Thomas H. Gallagher

Implementing Near‑Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned
Steven Crane, Philip D. Sloane, Nancy C. Elder, Lauren W. Cohen, Natascha Laughtenschlager, and Sheryl Zimmerman

Implementing Shared Decision-Making: Barriers and Solutions—An Orthopedic Case Study
Shawn L. Mincer, Michael J. Lee, Richard J. Bransford, Saint Adeogba, Karen L. Posner, Lynne S. Robins, Pornsak Chandanabhumma, Michelle S. Lam, Aaron S. Azose, and Karen B. Domino

Transitional Care Medication Safety: Stakeholders’ Perspectives
Cynthia F. Corbett, Alice E. Dupler, Suzanna Smith, E’lise M. Balogh, and Cory R. Bolkan

Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home
Joshua J. Neumiller, Stephen M. Setter, Allison M. White, Cynthia F. Corbett, Douglas L. Weeks, Kenn B. Daratha, and Jeffrey B. Collins

Disclaimer: The opinions presented in this publication are those of the authors and do not necessarily represent the position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

This publication is in the public domain and may be used and reprinted without permission, except for those items identified as protected by copyright. For these items, readers will need to contact the copyright holder for further permission to use and reproduce the materials. Citation as to source will be appreciated.

Suggested citation: Advances in Patient Safety and Medical Liability. Battles J, Azam I, Grady M, and Reback K, Eds. AHRQ Publication No. 17-0017-EF. Rockville, MD: Agency for Healthcare Research and Quality; August 2017.

Editors' Affiliations: James Battles, PhD, Former Project Officer (Retired); Irim Azam, MPH; Kathryn Reback, JD, MSN; Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality (AHRQ). Mary Grady, BS, Office of Communications, AHRQ.

Page last reviewed August 2017
Page originally created August 2017
Internet Citation: Advances in Patient Safety and Medical Liability. Content last reviewed August 2017. Agency for Healthcare Research and Quality, Rockville, MD.
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