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A Modified Communication and Optimal Resolution Program for Intersystem Medical Error Discovery: Protocol for an

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This summary is machine-generated.

This study adapts the Communication and Optimal Resolution (CANDOR) Toolkit for intersystem medical error discovery (IMED). The modified process aims to improve transparent communication and patient safety when errors are found across systems.

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Area of Science:

  • Healthcare quality improvement
  • Patient safety research
  • Medical error disclosure

Background:

  • Preventable medical errors are a significant public health issue, necessitating strategies for transparent communication and quality improvement.
  • The Agency for Healthcare Research and Quality (AHRQ) Communication and Optimal Resolution (CANDOR) Toolkit addresses transparent communication, error prevention, and patient resolution.
  • A gap exists in addressing medical errors discovered between systems (intersystem medical error discovery - IMED), lacking clear disclosure and feedback mechanisms.

Purpose of the Study:

  • To develop and test a modified CANDOR process specifically for application to intersystem medical error discovery (IMED) scenarios.
  • To enhance transparent communication and optimal resolution strategies for IMED within healthcare settings.

Main Methods:

  • A series of studies employing an implementation framework, starting with a consensus-building stakeholder panel to modify the CANDOR process.
  • Preimplementation analysis using the Consolidated Framework for Implementation Research to assess organizational readiness and individual behaviors via interviews and surveys.
  • Pilot testing of the developed implementation toolkit at two cancer centers, measuring five implementation outcomes (acceptability, appropriateness, reach, adoption, feasibility).

Main Results:

  • The study protocol was funded by AHRQ in August 2018 and approved by the University of Michigan Medical School Institutional Review Board.
  • As of April 2019, the first step of the first aim was underway, with completion projected for April 2020.
  • Data collection for subsequent aims was projected to commence in January 2020 and August 2020, respectively.

Conclusions:

  • Implementing a communication and resolution strategy for IMED scenarios will address a critical gap in patient safety.
  • The study is expected to yield insights into the utility of an implementation toolkit for improving transparent communication and resolution of IMED.
  • Future work will involve broader testing of the toolkit, understanding implementation barriers, and piloting in new organizations.