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Monday 5:34 CST, March 19, 2018


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October 11, 2017

New CANDOR toolkit from AHRQ helps with immediate response to patient safety events

A new Communication and Optimal Resolution (CANDOR) toolkit, available from the Agency for Healthcare Research and Quality, provides methods and tools that allow health systems and hospitals to respond immediately when patients are harmed by the care they are receiving. Despite the best efforts of doctors, nurses, and other health care professionals, research shows about 1 in 10 patients is harmed by medical care. 

By using CANDOR, MedStar Health — a health system in the Baltimore and Washington, D.C. area — reported reductions in serious patient safety events by about 65 percent, as well as reductions in the cost of care associated with serious safety events (including medical liability payments) by more than $70 million since 2012.

It achieved these results by implementing a comprehensive patient safety program that included objectives such as high reliability, human factors, and patient and family partnerships, as well as principles and strategies from the CANDOR toolkit. The process for CANDOR involves emphasizing the importance of reporting unanticipated patient harm events as soon as they happen. By learning from these events and engaging in candid, empathetic communication with patients and families, hospitals can provide a timely resolution for patients and families and make changes in the care models to prevent similar events from happening again.

David Mayer, MD, vice president of quality and safety at MedStar Health, said when a safety event occurs, the staff uses a “Go Team” approach, which is similar to the process the National Transportation Safety Board uses. He said three teams are activated:

  • A discovery and learning team
  • A care for the caregiver team
  • A patient and family communication team

Dr. Mayer said the CANDOR program also has led to greater transparency at MedStar Health because more employees through the years have been willing to report patient safety events without fear of retribution. 

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