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Essential Hospitals Improve Patient Safety with AHRQ Toolkit

Research shows medical care can cause harm to 1 in 10 patients. Not only can harm events devastate patients and families, they can have serious financial implications for hospitals and traumatize medical personnel.

Essential hospitals across the country have improved communication about patient safety events using the Agency for Healthcare Research and Quality (AHRQ) Communication and Optimal Resolution (CANDOR) toolkit. The toolkit includes eight modules to aid reporting and correction of unsafe conditions, improve communication with patients and families following patient harm events, and resolve situations in a timely manner.

Association members MedStar Health, in Washington, D.C., and Christiana Care Health System, in Wilmington, Del., participated in a two-year, AHRQ-funded demonstration project to test the CANDOR process.

MedStar Health reports a 65 percent reduction in serious patient safety events and a $70 million reduction in the cost of care associated with these events since launching its patient safety program in 2012. When a serious safety event occurs, the health system activates three teams: a discovery and learning team, a care for the caregiver team, and a patient and family communication team.

“With increased reporting and learning from these events when they occur, we can improve our systems and processes, without blaming people when unintentional mistakes do happen,” said David Mayer, MD, vice president of quality and safety for MedStar Health.

Christiana Care Health System also values its Care for the Caregiver program, which encourages supporting team members in the wake of adverse patient events. Leaders said the increase in patient safety reporting has not only encouraged greater transparency among staff, but also between staff and patients.

“We’ve done a much better job at communicating with patients and their families, and our medical staff has a better understanding of the importance of immediate disclosure following a patient safety event,” said Stephen Pearlman, MD, quality and safety offer for Women’s and Children’s Services at Christiana Care. “Patients feel positive about this more open approach.”

To learn more about the CANDOR toolkit, visit


About the Author

Emily Schweich is a communications manager at America's Essential Hospitals.

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