CANDOR: At the Heart of Patient Safety

Abstract

Experience suggests that changes to the 1986 Health Care Quality Improvement Act’s name-based reporting requirement would provide a regulatory path capable of fostering effective open communication about preventable medical error without the fear of malpractice claiming. The Agency for Healthcare Research and Quality (AHRQ) developed the Communication and Optimal Resolution (CANDOR) Toolkit with reliance on expert industry input and lessons learned from the AHRQ’s $23 million Patient Safety and Medical Liability grant initiative launched in 2009. CANDOR processes proactively engage healthcare providers, patients and their family in preventable harm communications. Experience has shown that this culture of open dialogue about preventable medical harm leads to organizational accountability and, when appropriate, successful early resolution. Lessons learned responses; applied system-wide have empirically demonstrated a reduction in future medical error and affiliated costs. Regulatory change has the power to help ally provider fear of litigation, provides for patient and family participation in care while addressing the reputational and economic concern providers face following medical error.