Institute for Healthcare Improvement: Respectful Management of Serious and Clinical Adverse Events

27 Oct 2010 | Adverse Events

In any health care clinical setting, adverse events occur frequently. This paper focuses particularly on those clinical adverse events with an impact of permanent psychological and/or physical  harm (or death) on one patient or many, often referred to as sentinel events.

The paper is designed to help health care executives and other organisational leaders (CEOs, COOs, CMOs and CNOs, legal counsel, public relations/communications and quality/safety/risk management professionals) develop a plan to deal with a serious clinical adverse event so  they are able to respond effectively and learn and improve safety as a result of it. Many organisations do not have a plan when a serious clinical adverse event occurs. In these cases, leaders can use this paper and the associated resources to guide their immediate and ongoing response.

Although the paper is designed to serve the US, in the preparation of this paper, we have worked with, benefited enormously from, and had review by international experts. We believe this document will be equally relevant to our international partners, with perhaps minor adaptations to local culture, context, and approaches.

Last updated 03/12/2021