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When Things go Wrong RESPONDING TO ADVERSE EVENTS

The hierarchical architecture is a straightforward extension of a centralized architecture. It only requires that the basic central server be modified to propa- gate any information that it receives (i.e., subscriptions, etc.) on to its “master” server. In fact, the server/server protocol we use within the hierarchical archi- tecture is exactly the same as the protocol described in Section 3 for commu- nication between the servers and the external clients of the event notification service. Thus, in terms of communication, a server is not distinguished from objects of interest or interested parties. In practice, this means that a server will receive subscriptions, advertisements, and notifications from its “client” servers,. | _ When Thingi Wrong RESPONDING TO ADVERSE EVENTS A Consensus Statement of the Harvard Hospitals MARCH 2006 The concepts and principles in this document are unanimously supported by the Harvard teaching institutions BETH ISRAEL DEACONESS HOSPITAL BRIGHAM AND WOMEN S HOSPITAL CAMBRIDGE HEALTH ALLIANCE CHILDREN S HOSPITAL DANA-FARBER CANCER INSTITUTE FAULKNER HOSPITAL JOSLIN DIABETES CENTER HARVARD VANGUARD MEDICAL ASSOCIATES MASSACHUSETTS EYE AND EAR INFIRMARY MASSACHUSETTS GENERAL HOSPITAL MCLEAN HOSPITAL MOUNT AUBURN HOSPITAL NEWTON-WELLESLEY HOSPITAL NORTH SHORE HOSPITAL SPAULDING REHABILITATION HOSPITAL VA BOSTON HEALTHCARE SYSTEM Copyright 2006 Massachusetts Coalition for the Prevention of Medical Errors All rights reserved. All or parts of this document may be photocopied for education not-for-profit uses. It may not be reproduced for commercial for-profit use in any form by any means electronic mechanical xerographic or other . This document may be downloaded or printed copies ordered from www.macoalition.org Foreword In March 2004 responding to evidence of wide variation in the way both Harvard hospitals and hospitals nationally communicate with patients about errors and adverse events a group of risk managers and clinicians from several Harvard teaching hospitals the School of Public Health and the Risk Management Foundation Malpractice Captive for the Harvard Teaching Institutions assembled to explore and discuss issues surrounding this subject. We soon agreed it would be useful to consider all aspects of an institution s response to an unanticipated event and to try to develop an evidence-based statement addressing these crucial issues. The Working Group began to meet monthly and quickly expanded to include patients and legal representatives. The resulting document was distributed to all of the Harvard-affiliated hospitals in April 2005 with the request that it be distributed widely within the institutions for discussion critique and modification as .