PS 105 Lesson 1: Responding to an Adverse Event: A Step-by-Step Approach
In the minutes and hours after a patient has an adverse event, you may not have all the facts about what happened. In this lesson, we’ll discuss what caregivers should say — and how to say it — immediately after such an event occurs. Because, as you'll see through several examples, communication is important. You’ll also learn who should handle this initial communication and who else may need to be notified about the event. 
Estimated Time of Completion: 20 minutes
Learning Objectives
After completing this lesson, you will be able to:
1. Describe the immediate steps caregivers should take when something goes wrong in a patient's care.
2. Explain the importance of communicating about adverse events and documenting them.
3. Explain the importance of seeking answers after adverse events and near misses.
Contributors
Author(s):
Frank Federico, RPh, Vice President, Senior Patient Safety Expert, Institute for Healthcare Improvement View Profile
Allan Frankel, MD, Managing Partner, Safe and Reliable Healthcare, Safe and Reliable Healthcare View Profile
Editor(s):
Laura Fink, Director, Editorial and Online Learning, Institute for Healthcare Improvement View Profile
Reviewer(s):
Barbara Edson, RN, MBA, MHA, VP, Clinical Quality, Health Research & Educational Trust (HRET) View Profile
Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health View Profile
Wendy Madigosky, MD, MSPH, Director, Foundations of Doctoring Curriculum, University of Colorado Anchutz Medical Center View Profile
Requirements
You must be a registered IHI.org user to take this lesson.
You must achieve a minimum score of 75% to successfully complete this lesson.