# Error Identification Between Health Systems—A Patient Safety Blind Spot

> **NIH AHRQ K08** · UNIVERSITY OF MICHIGAN AT ANN ARBOR · 2021 · $146,556

## Abstract

PROJECT SUMMARY
 Preventable medical errors represent a major public health problem. To prevent future errors, improve
disclosure, and mitigate malpractice risks, organizations have adopted strategies for early transparent
communication and emphasized quality improvement through peer review. These principles are incorporated
into the AHRQ Communication and Optimal Resolution (CANDOR) Toolkit, which facilitates 1) transparent
communication, 2) error prevention, and 3) achieving optimal resolution with patients and families.
 What physician's should do when they discover another physician's error is less clear. Application of the
CANDOR process may be particularly complex when the discovering and responsible physicians practice in
different facilities. Without clear expectations or mechanisms for disclosure and feedback on the part of the
discovering provider, it is uncertain to what extent and in what way these errors are being communicated with
patients or responsible providers. Further, known barriers to disclosure and reporting one's own error may
not be relevant or replaced by other unknown barriers when considering transparent communication
regarding another physician's error. Providing a communication and resolution strategy applicable to errors
discovered between physicians and facilities would help address this current blind spot in the patient safety
and quality improvement movement. We will investigate these questions through a series of studies
engaging stakeholders.
 This research will be the first to develop strategies to improve physician-to-physician communication over
sensitive patient scenarios representing complex ethical and professional challenges for many physicians.
Furthermore, the research project, multidisciplinary mentorship team, and unparalleled research environment
are ideally suited to address the career goals and educational needs of the candidate, Lesly Dossett, MD,
MPH. The proposal includes a detailed educational plan with training that will be essential for successful
completion of this research and for Dr. Dossett's career development. The training includes mentored
research and graduate level courses in implementation science. This career development award will lay the
groundwork for Dr. Dossett to perform ongoing, innovative health services research, and to become an
independent investigator.

## Key facts

- **NIH application ID:** 10233792
- **Project number:** 5K08HS026030-04
- **Recipient organization:** UNIVERSITY OF MICHIGAN AT ANN ARBOR
- **Principal Investigator:** LESLY A DOSSETT
- **Activity code:** K08 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2021
- **Award amount:** $146,556
- **Award type:** 5
- **Project period:** 2018-09-01 → 2022-08-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10233792

## Citation

> US National Institutes of Health, RePORTER application 10233792, Error Identification Between Health Systems—A Patient Safety Blind Spot (5K08HS026030-04). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10233792. Licensed CC0.

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