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Mahajan P, Mollen C, Alpern ER, Baird-Cox K, Boothman RC, Chamberlain JM, Cosby K, Epstein HM, Gegenheimer-Holmes J, Gerardi M, Giardina TD, Patel VL, Ruddy R, Saleem J, Shaw KN, Sittig DF, Singh H. An Operational Framework to Study Diagnostic Errors in Emergency Departments: Findings From A Consensus Panel. J Patient Saf 2021; 17:570-575. [PMID: 31790012 DOI: 10.1097/pts.0000000000000624] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To create an operational definition and framework to study diagnostic error in the emergency department setting. METHODS We convened a 17-member multidisciplinary panel with expertise in general and pediatric emergency medicine, nursing, patient safety, informatics, cognitive psychology, social sciences, human factors, and risk management and a patient/caregiver advocate. We used a modified nominal group technique to develop a shared understanding to operationally define diagnostic errors in emergency care and modify the National Academies of Sciences, Engineering, and Medicine's conceptual process framework to this setting. RESULTS The expert panel defined diagnostic errors as "a divergence from evidence-based processes that increases the risk of poor outcomes despite the availability of sufficient information to provide a timely and accurate explanation of the patient's health problem(s)." Diagnostic processes include tasks related to (a) acuity recognition, information and synthesis, evaluation coordination, and (b) communication with patients/caregivers and other diagnostic team members. The expert panel also modified the National Academies of Sciences, Engineering, and Medicine's diagnostic process framework to incorporate influence of mode of arrival, triage level, and interventions during emergency care and underscored the importance of outcome feedback to emergency department providers to promote learning and improvement related to diagnosis. CONCLUSIONS The proposed operational definition and modified diagnostic process framework can potentially inform the development of measurement tools and strategies to study the epidemiology and interventions to improve emergency care diagnosis.
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Affiliation(s)
| | - Cynthia Mollen
- Division of Pediatric Emergency Medicine, Department Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth R Alpern
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Richard C Boothman
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - James M Chamberlain
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's National Health System, Washington, District of Columbia
| | - Karen Cosby
- Emergency Medicine, Cook County Hospital (Stroger) and Rush Medical School, Chicago, Illinois
| | - Helene M Epstein
- Member of the Board of Directors, Brightpoint Care, New York, New York
| | | | - Michael Gerardi
- Emergency Medicine, Morristown Medical Center and Goryeb Children's Hospital, Morristown, New Jersey
| | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Vimla L Patel
- Center for Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, New York
| | - Richard Ruddy
- University of Cincinnati College of Medicine, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jason Saleem
- Industrial Engineering, University of Louisville, Louisville, Kentucky
| | - Kathy N Shaw
- Division of Pediatric Emergency Medicine, Department Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dean F Sittig
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
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Brenner MJ, Boothman RC, Rushton CH, Bradford CR, Hickson GB. Honesty and Transparency, Indispensable to the Clinical Mission-Part I: How Tiered Professionalism Interventions Support Teamwork and Prevent Adverse Events. Otolaryngol Clin North Am 2021; 55:43-61. [PMID: 34823720 DOI: 10.1016/j.otc.2021.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
At the foundation of clinical medicine is the relationship among patients, families, and health care professionals. Implicit to that social contract, professionals pledge to bring clinical excellence to advance their patients' wellness and healing-and to prevent harm. Patients trust that those privileged to deliver care will do so unwaveringly in service of patients' best interests; however, the incentives and infrastructure surrounding health care delivery can promote or undermine individual performance, teamwork, and patient safety. Modeling professionalism and identifying slips and lapses supports pursuit of high reliability. Part 1, Promoting Professionalism, introduces the first of 3 pillars of advancing the clinical mission.
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Affiliation(s)
- Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan School of Medicine, 1500 East Medical Center Drive SPC 5312, 1904 Taubman Center, Ann Arbor, MI 48109-5312, USA; GTC Quality Improvement Collaborative, Durham, NC, USA.
| | - Richard C Boothman
- Boothman Consulting Group, LLC, Ann Arbor, MI, USA; Department of Surgery, University of Michigan Medical School, Ann Arbor; Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cynda Hylton Rushton
- Johns Hopkins University School of Nursing, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Berman Institute of Bioethics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carol R Bradford
- The College of Medicine and James Cancer Hospital and Solove Research Institute; Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Gerald B Hickson
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Quality, Safety and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN, USA
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Affiliation(s)
- William M Sage
- School of Law and Dell Medical School, The University of Texas at Austin
| | - Richard C Boothman
- Boothman Consulting Group, LLC, Ann Arbor, Michigan
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Thomas H Gallagher
- Department of Medicine, Department of Bioethics and Humanities, University of Washington, Seattle
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Miller J, Vitous CA, Boothman RC, Dossett LA. Medical error professionals' perspectives on Inter-system Medical Error Discovery (IMED): Consensus, divergence, and uncertainty. Medicine (Baltimore) 2020; 99:e21425. [PMID: 32756147 PMCID: PMC7402729 DOI: 10.1097/md.0000000000021425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 06/02/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022] Open
Abstract
Best practices for how to respond are unclear when a medical error is discovered in a different system (inter-system medical error discovery or IMED). This qualitative study explored medical error professionals' views on disclosure, feedback, and reporting in these scenarios.We conducted semi-structured telephone interviews from January to September 2018 with 15 medical error professionals from 5 regions of the United States. Interview guides addressed perspectives on best practice, minimum obligations, and mediating factors with respect to IMED. Each transcript was coded independently by two investigators. Analysis followed the inductive approach of interpretive description.Medical error professionals expressed diverse views about minimum obligations and best practices for physicians when responding to IMED events. All cited practical barriers to disclosure, feedback, and reporting in these scenarios. There was general consensus that clear-cut, harmful errors should be disclosed to patients, and most advised investigation and feedback prior to disclosure. Respondents diverged in recommended best practices and thresholds for taking action. All noted the lack of guidance specific to IMED scenarios but differed in how they would extrapolate from more general guidance.While medical error professionals expressed consensus regarding obligations to disclose obvious errors, they differed on particulars. Guidelines or an algorithm could be very useful. Efforts to develop clear guidelines for IMED must take into account these factors, as well as practical and political challenges to communication about errors discovered across systems.
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Affiliation(s)
- Jacquelyn Miller
- Center for Bioethics and Social Sciences in Medicine (CBSSM)
- Center for Healthcare Outcomes and Policy (CHOP)
| | | | | | - Lesly A. Dossett
- Center for Bioethics and Social Sciences in Medicine (CBSSM)
- Center for Healthcare Outcomes and Policy (CHOP)
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Gallagher TH, Boothman RC, Schweitzer L, Benjamin EM. Making communication and resolution programmes mission critical in healthcare organisations. BMJ Qual Saf 2020; 29:875-878. [DOI: 10.1136/bmjqs-2020-010855] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 01/25/2023]
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Dossett L, Miller J, Jagsi R, Sales A, Fetters MD, Boothman RC, Dimick JB. A Modified Communication and Optimal Resolution Program for Intersystem Medical Error Discovery: Protocol for an Implementation Study. JMIR Res Protoc 2019; 8:e13396. [PMID: 31267984 PMCID: PMC6632107 DOI: 10.2196/13396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/15/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023] Open
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; however, how medical errors should be addressed when they are discovered between systems—intersystem medical error discovery (IMED)—remains unclear. Without mechanisms for disclosure and feedback on the part of the discovering provider, uncertainty remains as to the extent to which IMED is communicated with patients or responsible providers. Furthermore, known barriers to disclosure and reporting one’s own error may not be relevant or may be replaced by other unknown barriers when considering scenarios of IMED. Objective This study aims to develop and test implementation of a modified CANDOR process for application to IMED scenarios. Methods We plan a series of studies following an implementation framework. First, we plan a participatory, consensus-building stakeholder panel process to develop the modified CANDOR process. We will then conduct a robust preimplementation analysis to identify determinants of implementation of the modified process. Using the Consolidated Framework for Implementation Research 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 2 cancer centers, sites where IMED is hypothesized to occur more frequently than other settings. We will measure 5 implementation outcomes (acceptability, appropriateness, reach, adoption, and feasibility) using a combination of key informant interviews and surveys over the pre- and postimplementation phases. Results This protocol was funded in August 2018 with support from the AHRQ. The University of Michigan Medical School Institutional Review Board has reviewed and approved the scope of activities described. As of April 2019, step 1 of aim 1 is underway, and aim 1 is projected to be completed by April 2020. Data collection is projected to begin in January 2020 for aim 2 and in August 2020 for aim 3. Conclusions Providing a communication and resolution strategy applicable to IMED scenarios will help address the 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. International Registered Report Identifier (IRRID) PRR1-10.2196/13396
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Affiliation(s)
- Lesly Dossett
- Center for Health Outcomes and Policy, Institute for Health Policy and Innovation, Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Jacquelyn Miller
- Center for Bioethics and Social Sciences Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Reshma Jagsi
- Center for Bioethics and Social Sciences Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
| | - Anne Sales
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI, United States
| | - Michael D Fetters
- Mixed Methods Research and Scholarship Program, Department of Family Medicine, Ann Arbor, MI, United States
| | - Richard C Boothman
- Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Justin B Dimick
- Center for Health Outcomes and Policy, Institute for Health Policy and Innovation, Department of Surgery, University of Michigan, Ann Arbor, MI, United States
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Affiliation(s)
- Richard C Boothman
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.,University of Michigan Health System, Ann Arbor, MI
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Mello MM, Boothman RC, McDonald T, Driver J, Lembitz A, Bouwmeester D, Dunlap B, Gallagher T. Communication-And-Resolution Programs: The Challenges And Lessons Learned From Six Early Adopters. Health Aff (Millwood) 2014; 33:20-9. [DOI: 10.1377/hlthaff.2013.0828] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michelle M. Mello
- Michelle M. Mello ( ) is a professor of law and public health, Harvard School of Public Health, in Boston, Massachusetts
| | - Richard C. Boothman
- Richard C. Boothman is chief risk officer, University of Michigan Health System, in Ann Arbor
| | - Timothy McDonald
- Timothy McDonald is chief safety and risk officer for health affairs, University of Illinois at Chicago
| | - Jeffrey Driver
- Jeffrey Driver is CEO of the Risk Authority, Stanford University Medical Network, in Stanford, California
| | - Alan Lembitz
- Alan Lembitz is chief medical officer of COPIC Insurance, in Denver, Colorado
| | - Darren Bouwmeester
- Darren Bouwmeester is administrator of the REACT (Respond Effectively And Communicate Timely) Program at Coverys, in Boston
| | - Benjamin Dunlap
- Benjamin Dunlap is a research assistant in the Department of Medicine, University of Washington School of Medicine, in Seattle
| | - Thomas Gallagher
- Thomas Gallagher is a professor in the Department of Medicine and the Department of Bioethics and Humanities, University of Washington School of Medicine
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Bell SK, Smulowitz PB, Woodward AC, Mello MM, Duva AM, Boothman RC, Sands K. Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation. Milbank Q 2013; 90:682-705. [PMID: 23216427 DOI: 10.1111/j.1468-0009.2012.00679.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
CONTEXT The Disclosure, Apology, and Offer (DA&O) model, a response to patient injuries caused by medical care, is an innovative approach receiving national attention for its early success as an alternative to the existing inherently adversarial, inefficient, and inequitable medical liability system. Examples of DA&O programs, however, are few. METHODS Through key informant interviews, we investigated the potential for more widespread implementation of this model by provider organizations and liability insurers, defining barriers to implementation and strategies for overcoming them. Our study focused on Massachusetts, but we also explored themes that are broadly generalizable to other states. FINDINGS We found strong support for the DA&O model among key stakeholders, who cited its benefits for both the liability system and patient safety. The respondents did not perceive any insurmountable barriers to broad implementation, and they identified strategies that could be pursued relatively quickly. Such solutions would permit a range of organizations to implement the model without legislative hurdles. CONCLUSIONS Although more data are needed about the outcomes of DA&O programs, the model holds considerable promise for transforming the current approach to medical liability and patient safety.
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Affiliation(s)
- Sigall K Bell
- Beth Israel Deaconess Medical Center of Harvard Medical School, Boston, MA 02215,
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Boothman RC, Imhoff SJ, Campbell DA. Nurturing a culture of patient safety and achieving lower malpractice risk through disclosure: lessons learned and future directions. Front Health Serv Manage 2012; 28:13-28. [PMID: 22432378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In mid-2001 and early 2002, the University of Michigan Health System systematically changed the way it responded to patient injuries and medical malpractice claims. Michigan adopted a proactive, principle-based approach, described as an "open disclosure with offer" model, built on a commitment to honesty and transparency. Implementation was followed by steady reduction in the number of claims and various other metrics, such as elapsed time for processing claims, defense costs, and average settlement amounts. Though the model continues to evolve, it has retained its core components and the culture it nurtured while spurring other initiatives such as a unique approach to peer review. In this article we review our experience, identify the essential practical components of our model, offer suggestions for tailoring the approach to other settings, and present some thoughts as to the future of this approach.
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Ross PT, McMyler ET, Anderson SG, Saran KA, Urteaga-Fuentes A, Boothman RC, Lypson ML. Trainees' perceptions of patient safety practices: recounting failures of supervision. Jt Comm J Qual Patient Saf 2011; 37:88-95. [PMID: 21939136 DOI: 10.1016/s1553-7250(11)37011-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Ensuring that trainees receive appropriate clinical supervision is one proven method for improving patient safety outcomes. Yet, supervision is difficult to monitor, even more so during advanced levels of training. The manner in which trainees' perceived failures of supervision influenced patient safety practices across disciplines and various levels of training was investigated. METHODS A brief, open-ended questionnaire, administered to 334 newly hired interns, residents, and fellows, asked for descriptions of situations in which they witnessed a failure of supervision and their corresponding response. RESULTS Of the 265 trainees completing the survey, 73 (27.5%) indicated having witnessed a failure of supervision. The analysis of these responses revealed three types of supervision failures-monitoring, guidance, and feedback. The necessity of adequate supervision and its accompanying consequences were also highlighted in the participants responses. CONCLUSIONS The findings of this study identify two primary sources of failures of supervision: supervisors' failure to respond to trainees' seeking of guidance or clinical support and trainees' failure to seek such support. The findings suggest that the learning environment's influence was sufficient to cause trainees to value their appearance to superiors more than safe patient care, suggesting that trainees' feelings may supersede patients' needs and jeopardize optimal treatment. The literature on the impact of disruptive behavior on patient care may also improve understanding of how intimidating and abusive behavior stifles effective communication and trainees' ability to provide optimal patient care. Improved supervision and communication within the medical hierarchy should not only create more productive learning environments but also improve patient safety.
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Affiliation(s)
- Paula T Ross
- Department of Health Behavioral and Health Education, School of Public Health University of Michigan, Ann Arbor, Michigan, USA.
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McMyler ET, Ross PT, Saran KA, Urteaga-Fuentes A, Anderson SG, Boothman RC, Lypson ML. Mainstreaming risk management education into new resident and fellow orientation. J Grad Med Educ 2011; 3:395-9. [PMID: 22942971 PMCID: PMC3179220 DOI: 10.4300/jgme-d-10-00143.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Revised: 12/15/2010] [Accepted: 02/28/2011] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Understanding patient safety events and causative factors is an important step in reducing preventable adverse events. The University of Michigan's Graduate Medical Education (GME) Office, Department of Risk Management (DRM), and Office of Clinical Affairs (OCA) collaborated to incorporate a video workshop as a formal introduction to patient safety during orientation for new residents and fellows. This workshop reinforced the importance of effective communication and supervision in patient safety. METHODS DRM and OCA produced a video depicting an actual, unanticipated outcome that resulted from a constellation of preventable circumstances, which allows the audience to observe communication and supervision issues that lead to a patient death. The video is followed by a discussion of the patient safety issues seen, why they occurred, and strategies for improvement. Trainee perceptions of the value of the experience were surveyed and collected using a qualitative survey. RESULTS Most responders found the video workshop helpful. Trainees perceived the video and facilitated discussion as an effective way to identify patient safety issues, available resources, and the culture of patient safety at the institution. CONCLUSION Trainee comments supported the video workshop as an effective way to highlight the importance of communication and supervision in relation to patient safety. In the future, the DRM, OCA, and GME hope to reinforce this shared vision of patient safety through combined educational efforts.
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Affiliation(s)
- Eileen T McMyler
- Corresponding author: Eileen T. McMyler, 300 NIB 8A, 300 North Ingalls, Ann Arbor, MI 48130,
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Boothman RC, Blackwell AC, Campbell DA, Commiskey E, Anderson S. A better approach to medical malpractice claims? The University of Michigan experience. J Health Life Sci Law 2009; 2:125-159. [PMID: 19288891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The root causes of medical malpractice claims are deeper and closer to home than most in the medical community care to admit. The University of Michigan Health System's experience suggests that a response by the medical community more directly aimed at what drives patients to call lawyers would more effectively reduce claims, without compromising meritorious defenses. More importantly, honest assessments of medical care give rise to clinical improvements that reduce patient injuries. Using a true case example, this article compares the traditional approach to claims with what is being done at the University of Michigan. The case example illustrates how an honest, principle-driven approach to claims is better for all those involved-the patient, the healthcare providers, the institution, future patients, and even the lawyers.
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Boothman RC. Apologies and a strong defense at the University of Michigan Health System. Physician Exec 2006; 32:7-10. [PMID: 16615397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
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Boothman RC. Torts--wrongful pregnancy--when defendant's negligence or breach of contract in a sterilization procedure allows the conception and birth of a healthy child, damages may be recovered. Univ Detroit J Urban Law 2001; 57:184-201. [PMID: 11661924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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