CANDOR and the Importance of Honesty

Communication is a critical element underlying patient safety. We in health care usually think we do a pretty good job of encouraging communication among clinicians and between clinician and patient. Unfortunately, our colleagues and, most importantly our patients, think we can and should do better. There is one occasion in particular when communication is often poor and sometimes even discouraged: when a patient is harmed by the care he or she receives.

This is why a new AHRQ toolkit is so helpful. The Communication and Optimal Resolution (CANDOR) toolkit gives hospitals, health systems, and clinicians the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and clinicians.

Here's why CANDOR matters: when an adverse event occurs, hospitals and providers often clam up. What had been a medical process suddenly becomes a legal one. This serves nobody—not the patient, not the clinician, and not the hospital.

The CANDOR process envisions a different approach. It doesn't pretend that adverse events don't happen. Instead, it recognizes that, despite our best intentions, adverse events do occasionally happen, and sometimes have consequences—and it provides helpful guidance for handling them in a timely, honest, and compassionate way that also leads to preventing similar outcomes in the future.

CANDOR is necessary because the culture in many institutions results in a "wall of silence" following an adverse event. I can understand how this happens. From my first day in medical school through my residency, I was constantly reminded that it was my job to avoid making any mistakes because the consequences for patients can mean life or death. This would be true for all physicians in training as well as for those training as nurses and other types of health care practitioners.

But mistakes do happen—much more frequently than we would like to admit. It has been estimated that medical errors are the third-leading cause of death in the United States and that the majority of clinicians have experience with a medical error that resulted in harm to a patient. Often these "mistakes" are not the result of poorly trained individuals but the result of the faulty systems we sometimes work in.

The moment when an adverse event emerges can be one of the most confusing and scary times of a clinician's career. We might feel embarrassed, defensive, guilty, or even angry. We work so hard to diagnose and heal patients, but we are usually unprepared to talk about adverse events and medical errors when they occur.

The CANDOR process encourages us to proactively disclose harm to patients and families as soon as it happens. It is also important for us to engage with colleagues to reflect on the mistake and explore the root causes of how it happened. This helps us to learn from the situation and take steps to minimize the chances of a similar mistake happening again to another patient.

One important aspect of CANDOR is where it came from: the Agency's $23 million Patient Safety and Medical Liability grant initiative, which launched in 2009. This initiative is the largest Federal investment in research linking improved patient safety to reducing medical liability. But—and this is an important point—CANDOR doesn't prevent patients and families from pursuing lawsuits. Instead, it fosters open discussion with patients and families to resolve matters in a timely and appropriate manner.

The CANDOR toolkit is a brand new addition to AHRQ's suite of patient safety tools and training materials—we introduced it today at the National Patient Safety Foundation's 18^th Annual Congress in Arizona. I encourage hospital leaders as well as clinicians to check out the CANDOR toolkit and watch the introductory video to see how this new perspective on handling adverse events might help. I believe it will make care safer in the long run and give you the tools to engage in a meaningful, productive discussion with your patients, to everyone's benefit.