Cover: Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise

Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise

Published in: Health Services Research, 2016

Posted on Nov 11, 2016

by Thomas H. Gallagher, Brandelyn Bergstedt, Jason Michel Etchegaray, Amelia M. Chappelle, Madelene J. Ottosen, Emily W. Sedlock, Eric J. Thomas

Research Question

  1. What lessons can be learned from a patient-created exercise that simulates stakeholder response to patient and family experiences following adverse events?


The response to adverse events can lack patient-centeredness, perhaps because the involved institutions and other stakeholders misunderstand what patients and families go through after care breakdowns.

Study Setting

Washington and Texas.

Study Design

The HealthPact Patient and Family Advisory Council (PFAC) created and led a five-stage simulation exercise to help stakeholders understand what patients experience following an adverse event. The half-day exercise was presented twice.

Data Collection and Analysis

Lessons learned related to the development and conduct of the exercise were synthesized from planning notes, attendee evaluations, and exercise discussion notes.

Principal Findings

One hundred ninety-four individuals attended (86 Washington and 108 Texas). Take-homes from these exercises included the fact that the response to adverse events can be complex, siloed, and uncoordinated. Participating in this simulation exercise led stakeholders and patient advocates to express interest in continued collaboration.


A PFAC-designed simulation can help stakeholders understand patient and family experiences following adverse events and potentially improve their response to these events.

Key Findings

  • The current response to adverse events may lack patient-centeredness because it can be siloed and uncoordinated.
  • Patients' interest may not be the top priority for many stakeholders in response to adverse events.
  • Experiential, patient-directed learning can help stakeholders appreciate what it feels like to be a patient who has experienced an adverse event.

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