When Things Wrong

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RESPONDING TO ADVERSE EVENTSA Consensus Statement of the Harvard HospitalsMARCH 2006WhenThingsWronggoThe concepts and principles in this document are unanimously supported by the Harvard teaching institutions:BETH ISRAEL DEACONESS HOSPITALBRIGHAM AND WOMEN S HOSPITALCAMBRIDGE HEALTH ALLIANCECHILDREN S HOSPITALDANA-FARBER CANCER INSTITUTEFAULKNER HOSPITALJOSLIN DIABETES CENTERHARVARD VANGUARD MEDICAL ASSOCIATESMASSACHUSETTS EYE AND EAR INFIRMARYMASSACHUSETTS GENERAL HOSPITALMCLEAN HOSPITALMOUNT AUBURN HOSPITALNEWTON-WELLESLEY HOSPITALNORTH SHORE HOSPITALSPAULDING REHABILITATION HOSPITALVA BOSTON HEALTHCARE SYSTEMCopyright 2006 Massachusetts Coalition for the Prevention of Medical ErrorsAll rights reserved. All or parts of this document may be photocopied for education, not-for-profit uses. It may not be reproducedfor commercial, for-profit use in any form, by any means (electronic, mechanical, xerographic, or other).

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

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