Siegfried Hecker and Scott Sagan published new essays on the North Korean nuclear crisis. In his article in the Bulletin of the Atomic Scientists, Hecker said, "we need the political equivalent of control rods, which get inserted into a nuclear reactor core to prevent a runaway catastrophic reaction." Sagan, in a Foreign Affairs magazine essay, urges a deterrence strategy for the U.S., because, "when it comes to the current conflict with North Korea, that means admitting that there are no military options that do not risk starting the most destructive war since 1945."

Deep policy discussions between journalists and top Stanford scholars highlighted a recent media roundtable at the Hoover Institution.

The event drew about 30 members of the national media from a variety of print and broadcast outlets, including CNN, CBS, The New York Times, Wall Street Journal, MSNBC, The Washington Post, and Politico.  The two-day media roundtable on Oct. 15-16 was titled, “Outside the Beltway.”

Over the course of the two-day conference, participants engaged in robust discussions with Hoover Institution fellows and Freeman Spogli Institute for International Studies scholars, including former U.S. Secretary of State and Hoover and FSI senior fellow Condoleeza Rice, who kicked off the event with a foreign policy conversation.

Drones and cybersecurity, for example, were topics of conversation for Amy Zegart and Herb Lin from the Center for International Security and Cooperation (CISAC).

Drones and new warfare

Zegart said, “New technology is being used in ways never imagined ... The question is, could drones be next?”

Drones are possible “coercion tools,” more effective than people would believe, Zegart said. “We need to figure out how the logic works with coercion, in regard to states.”

How do you get others to back down without a fight? You need to issue a costly threat, she said. For example, “trip-wire” forces of more than 20,000 in South Korea represent such a credible threat to North Korea. “Low-cost is low credibility,” or “cheap talk,” on the other hand.

Drones lower the cost of coercion, Zegart said. One point is that such strikes have huge public support, as the risk of U.S. casualties are very low, according to polls – 62 percent favor such drone strikes.

Zegart said drones could shift the “relative costs” of war and are better able to sustain military action over a lengthy time frame. They also affect the “psychology of punishment.” Hovering over a target for long periods of time, decapitation strikes against regime leaders, and the constant state of “near-ambush” changes the character of war and for a military campaign to stay the course.

“Certainty of punishment is a very powerful way to change the behavior of the adversary,” moreso than “severity of punishment, said Zegart, who has affirmed these conclusions through surveys with foreign military officers. That research also showed that domestic political support for military reaction is the most popular reason for making threats credible. But a deeper dive into such issues is urged, she added.

“We’re really behind the curve in figuring out how to make military threats credible in the world,” said Zegart. “Lots of questions remain.”

Hacking, information attacks

Lin spoke about the recent Equifax data hacking, among other topics.

He said, “The harm we all feel is both tangible and intangible” in regard to such hacks. In other words, there is both material threat and a peace of mind threat, he explained.

The “Internet-of-Things” is another looming problem, Lin said. In the future, liability issues will factor into how all these devices are connected and who is responsible in case of misdeeds, he said.

In the case of health care, confidentiality is a critical societal goal, but hacking creates numerous scenarios: “Would you prefer your blood type posted online or changed in your medical records,” Lin said, explaining the different ways information misuse may affect people.

On the global security front, “cyber war” takes advantage of the flaws of information technology (IT), and “information warfare” takes advantage of the virtues of IT, he noted. Such efforts begin to level the playing field between international actors and agencies.

“You give large megaphones to small players,” Lin said.

In Russia, information warfare is actually studied as a theory of warfare. And the results show that it works – it’s easier to destroy democratic  values online than create or reinforce them, Lin said. For example, Russia’s meddling in the 2016 elect stoked political polarization in America.

One media member asked Lin how the U.S. could prevent Russia from using cyber and information warfare in upcoming U.S. elections.

Lin said, “It’s not clear to me that the U.S. government is really going to be willing to do anything,” but some public pressure may move entities like media companies to respond more effectively.

And Zegart noted, “The Russians are still here.” They are present right now in any number of settings, from social media to traditional media and in public spheres, for example, she said.

“Attacking brains” was how Zegart described Russia’s goal. For American social media companies, she suggested, “Think about battleground states” and focus on “triaging” these areas.

WWII, Russia

The media also heard presentations from Hoover's Kori Schake on defense policy; Hoover's Victor Davis Hanson on “The Second World Wars,” his new book; Hoover's Michael Auslin on the Asian century; Hoover and FSI's Michael McFaul discussed the U.S-Russia relationship; and Hoover and FSI's Larry Diamond on democracy in the world order.

McFaul spoke about the hot spots in the relationship between the U.S. and Russian governments, his time as the U.S. ambassador to Russia during the Obama administration, and his suggested approaches to today’s engagement with Russia. He noted how Russia's President Vladimir Putin has prevailed on many recent occasions against the best interests of the U.S. One instance is Syria and how complicated that issue was for foreign policy makers during his tenure.

"The objective we sought to achieve -- the end of the civil war -- our policies did not achieve," said McFaul, who urges stronger U.S. action against Russian cyber attacks on the U.S. electoral process, now and into the future.

Hanson said that people today often fail to appreciate the deadly scope of the WWII conflict. For example, he pointed out that more people died in that conflict than any in human history, with 27,000 people dying every day in WWII. It was also the first time that more civilians were killed than soldiers. Of all the six major powers involved in the conflict, Japan killed about 10 people for every person they lost.

Lessons from WWII? “Things change very quickly in a war,” Hanson said. In 1942, it looked like the Axis powers had the upper hand; the next year, the Allies were surging. Also, a country should rely on a formidable deterrence strategy to discourage would-be attackers.

Once you lose it, “deterrence is very, very hard to recapture,” Hanson said.

MEDIA CONTACTS:

Clifton B. Parker, Center for International Security and Cooperation: (650) 725-6488, cbparker@stanford.edu

If the U.S. abandoned the Iran nuclear deal, it would harm America’s credibility on nonproliferation issues and make it more difficult to solve the North Korean crisis, Stanford scholars say.

The Trump administration is soon expected to “decertify” or send the Iran nuclear agreement to Congress for reconsideration. Signed in 2015, the nuclear deal framework is between Iran and what is known as the “P5+1” group of world powers: the United States, United Kingdom, France, China, Russia and Germany.

Advocates of the deal say it helped avert a possible war with Iran and a Middle Eastern nuclear arms race. Critics say it will only delay Iran’s march toward a nuclear bomb. The agreement aims to limit Iran’s ability to create nuclear weapons; in return, Iran received relief from economic penalties and sanctions.

The Stanford News Service spoke with two experts about the deal.

• Siegfried Hecker is a top nuclear security expert, former Los Alamos National Laboratory director and senior fellow at the Center for International Security and Cooperation.
• Abbas Milani is the Hamid and Christina Moghadam Director of Iranian Studiesand affiliate at FSI’s Center on Democracy Development and the Rule of Law.

If the U.S. cancels the Iran nuclear deal, could Iran follow a similar path that North Korea has taken? 

Hecker: An important lesson the Trump administration should learn is from what happened in October 2002 when the Bush administration couldn’t wait to walk away from the Clinton administration’s “Agreed Framework” deal with Pyongyang. That led to North Korea withdrawing from the Nuclear Nonproliferation Treaty, expelling the international inspectors and building a nuclear bomb. Walking away from the Iran deal now could similarly open the doors for Tehran to build a nuclear bomb.

How might this change our relationships with other countries and nuclear powers?

Hecker: The other parties that signed the Iran deal are all strongly in favor of keeping the deal, so it will leave the U.S. even more isolated than it has already become. It is not clear what the effect would be in Israel where Prime Minister Benjamin Netanyahu opposes the deal, but where many voices favor it.

Are the inspection standards in this deal rigorous? 

Hecker: The deal has more stringent inspection regimes and rights than previous nuclear agreements. Some in the U.S. call for even more intrusive inspections, such as to defense sites, that essentially no country is willing to have inspected. I think the agreement was able to get more than I ever thought possible.

How is the deal perceived in Iran?

Milani: I think the critical point to know is that there is not one voice or view that reflects the hopes and aspirations of Iran. The radical conservatives among the clergy and the Islamic Revolutionary Guard Corps were critical of the deal. They condemned it as the most “shameful” agreement in modern Iranian history. They lambasted Foreign Minister Mohammad Javad Zarif and President Hassan Rouhani for having made far too many concessions. Ali Khamenei, the Supreme Leader, tried to keep a safe distance from the deal – lest he antagonize his badly needed and shrinking radical conservative base – and yet, at every major turn, endorsed it.

For the regime, faced with calamitous economic challenges, having the deal and ending the sanctions was an existential must. For the same reason, the vast majority of Iranians, facing the drudgeries of a dying economy, favored the deal. They also hoped that the deal would usher in new relations with the world and the U.S. – a possible harbinger for a more free Iran.

How would Iran likely react to a strict enforcement approach often urged by the Trump administration?

Milani: It is not clear what the Trump administration means by a more “strict enforcement.” The agreement has placed fairly rigorous limits on Iran’s nuclear activity given the unique abilities of the International Atomic Energy Agency (IAEA) to monitor the program. Might Iran cheat? It might, but no “strict” enforcement can eliminate such a possibility.

There are, moreover, areas that have by all accounts been consciously left ambiguous in the deal. Is, for example, Iran required to curtail its missile program or contain its regional activities? Iran is adamant that these provisions were never part of the deal. Finally, the Trump administration’s notion that Iran is not abiding by the “spirit” of the deal is hard to enforce. One side’s perceived spirit might be deemed by the other side as nothing but wishful thinking.

Are there ways the deal could be strengthened and Iran’s regional ambitions checked?

Milani: There surely are ways to strengthen any deal.  The first step is, by clear indication, that all sides will abide by it. The U.S. is now the only country in the agreement that has indicated its desire to abrogate the deal. You can’t strengthen a deal you no longer are a part of.

It will be a bonanza for the radical conservatives if the U.S. unilaterally walks away from the deal. Khamenei’s mantra that the U.S. can never be trusted will be confirmed, Iran will harvest the economic benefits of the end of sanctions and radical conservatives will be able to blame their own failed management on U.S. sanctions.

MEDIA CONTACTS

Siegfried Hecker, Center for International Security and Cooperation: (650) 725-6468, shecker@stanford.edu

Abbas Milani, Iranian Studies: (650) 721-4052, amilani@stanford.edu

Clifton B. Parker, Center for International Security and Cooperation: (650) 725-6488, cbparker@stanford.edu

Read this story on the Stanford News Service web site.

Harold Trinkunas, CISAC's deputy director, and Richard Feinberg, a UC San Diego professor, co-authored the following op-ed in The Hill:

In an escalation of hostilities toward Cuba that is rapidly dismantling the Obama era détente, the Trump administration on Tuesday expelled 15 Cuban diplomats. The administration has also sharply drawn down the staff of the U.S. Embassy in Havana. The administration argues that the Cuban government has failed to provide safety to U.S. diplomats, 22 of whom fell victim in a mysterious rash of illnesses, even as the precise causes and perpetrators have yet to be identified. The U.S. government does not accuse the Cuban government for the unexplained illnesses.

A State Department travel advisory preceded the diplomatic expulsions, warning Americans against going to Cuba, although not one visitor has been affected by these illnesses. This extraordinary measure will undermine the island’s fastest growing source of foreign exchange earnings. Many of our professional diplomats, both those stationed in Havana and those at the State Department, oppose the dramatic downsizing of the U.S. and Cuban missions. While all are concerned for the safety of U.S. personnel, the health incidents seem to be in sharp decline. The U.S. diplomats in Havana are proud of the gains in advancing U.S. interests in Cuba, and they wish to continue to protect and promote them.

These punitive measures are about much more than protecting U.S. citizens. Rather, this White House and its pro-embargo allies in Congress have opportunistically seized on these mysterious illnesses affecting U.S. diplomats to overturn the pro-normalization policies of a previous administration, using bureaucratic obstruction and reckless language when they cannot make the case for policy change on the merits alone.

By taking these precipitous actions, this White House is doing exactly what our adversaries in the region seek to provoke. Overt U.S. hostility empowers anti-American hardliners in the Cuban regime opposed to stronger bilateral relations between the two countries. In addition, American travel to Cuba benefits the privately-operated segments of the Cuban tourism sector, and strengthens the emerging Cuban middle class. The travel advisory will harm these progressive segments of Cuban society.

Furthermore, a breakdown in U.S.-Cuban relations allows Russia, China, Iran and Venezuela to deepen their influence in Cuba and the broader Caribbean Basin. By pushing Cuba away, the U.S. is pushing it towards other actors whose interests are not aligned with our own. The Trump administration’s ill-considered actions towards Cuba are part of a broader pattern of disrespect for U.S. diplomacy from this White House, apparently without careful consideration of the geopolitical consequences. From attacking the deal to restrain Iran’s nuclear ambitions to provoking a nuclear North Korea to attacking the NAFTA trade accord with America’s two largest trade partners, Mexico and Canada, the Trump White House has steadily diminished U.S. influence and credibility abroad.

Our partners in Latin America welcomed the change in U.S. policy towards Cuba in 2014 as a sign that the Cold War had finally ended in the Western Hemisphere. The administration’s retreat from the opening towards Cuba alarms our friends in the Americas and calls into question the enduring value of U.S. commitments, much as belligerent statements toward Iran and North Korea harm our credibility with our allies in Europe and Asia. This pattern of reckless animus towards diplomacy comes at a cost to the international reputation of the U.S. with no apparent gain for our interests abroad.

There might have been an opportunity for creative diplomacy in this latest crisis. The Cuban government has been unusually collaborative with the U.S. in investigating these incidents involving U.S. diplomats. Cuba has allowed the FBI to operate independently in Cuba for the first time in more than 50 years, a signal of the importance that President Raul Castro assigns to improved relations with the U.S. But this White House seems bound and determined to continue down the path of obstruction, despite the costs. U.S. hostility risks damaging the coming transition to a new Cuban government after President Raul Castro steps down in early 2018 by strengthening the hand of anti-American hardliners who oppose further economic opening on the island.

It damages Cuban-Americans and their families by impeding travel and the flow of funding associated with their visits, and those of other American visitors, which have allowed the Cuban private sector to gain traction. It also damages U.S. relations with our partners in the region, who have long criticized what they see as senseless hostility between the U.S. and Cuba. And finally, the Trump administration’s approach serves to widen the door to U.S. geopolitical adversaries, such as Russia and Venezuela, to advance their interests in Cuba and in the region.

Harold Trinkunas is deputy director of the Center for International Security and Cooperation and a nonresident senior fellow at the Brookings Institution.

Richard Feinberg is a professor at the School of Global Policy and Strategy at the University of California San Diego and a nonresident senior fellow at the Brookings Institution. He is author of “Open for Business: Building the New Cuban Economy.”

At 90, William J. Perry has seen a lot in this world.

Maybe, in fact, too much. When it comes to nuclear warfare and annihilation, few people alive have contemplated such tragic outcomes quite like Perry, a senior fellow at the Center for International Security and Cooperation (CISAC), a former U.S. secretary of defense, and one of the world’s top nuclear weapons experts.

Perry, who becomes a nonagenarian on Oct. 11, has been called America’s “nuclear conscience.” He has sometimes referred to himself as a “prophet of doom,” and certainly not in a congratulatory sense, but more as a scientist on a mission. A brilliant mathematician who's worked with nearly every administration since Eisenhower, Perry's been up-close to nuclear weapons and near-miss crises for the last several decades.

Today, Perry is devoted to education on the subject of nuclear weapons – he understands exactly how much horror they would wreak on humanity and beyond.

And while no one would call Perry a crusader type (he is pragmatic, modest and private), there’s no doubt he’s on an energetic crusade for a nuclear-free world. Reaching young minds – those who will inherit the leadership of this world – is his calculus in the formula of world peace.

So, Perry reaches out in ways that resonant with youth. Last year created a series of virtual lectures, "Living at the Nuclear Brink," known as a MOOC, or massive open online course. His new online course, "The Threat of Nuclear Terrorism," launches Oct. 17.  

“Nuclear weapons may seem like 20th century history, but the choices we make about these weapons in the 21st century will decide your future in truly fundamental ways,” Perry wrote in the earlier course's introduction.

Conversations with conscience

An engineer and policy maker, Perry has academic affiliations that range widely across the Stanford campus. He is the Michael and Barbara Berberian Professor (emeritus), a senior fellow at the Freeman Spogli Institute for International Studies, and a senior fellow at the Hoover Institution. He's always in demand for a panel discussion or speaker event.

On Nov. 1, he's the featured subject of a CISAC event, "A Conversation with William J. Perry: Assessing Nuclear Risk in a New Era." That talk will include a Perry discussion with CISAC co-director Amy Zegart and another panel discussion, led by CISAC co-director Rod Ewing, with scholars Siegfried Hecker, David Holloway and Scott Sagan.

Perry's been known to participate in “Ask Me Anything” chats on Reddit, a place popular with youth. He connects with all types of audiences, conveying in direct encounters the exact nature of the nuclear dangers now facing civilization, and what can be done to reduce those dangers. This mission to educate led him to write a memoir, My Journey at the Nuclear Brink, all the while giving countless media interviews and delivering major speeches before major think tanks, nongovernmental organizations and policymakers.

One core Perry message is that U.S. foreign policies do not reflect the existing danger of nuclear threats -- the reason is that this risk isn’t widely recognized across society. And young people need to understand this dynamic that creates a distorted, too complacent view of a very real nuclear weapons problem throughout the world.

Perry, with the help of both his daughter, Robin Perry, his son, David Perry, granddaughter, Lisa Perry, and grandson Patrick Allen, established the William J. Perry Project, which informs the public about the role of nuclear weapons in today's world, while urging the elimination of these weapons.

It’s a family on a mission, and the Perrys believe the only way to avoid nuclear war is by directly contemplating the scenario in a personal, direct sense through learning and education.

"We're really just out there trying to reach a generation that isn't engaged on this issue right now," said Lisa Perry in an article on the Perry Project web site. She is the digital media manager for the project. "It's something we learned in history class. There was no conversation about what's happening now."

As her grandfather explained, "The dangers will never go away as long as we have nuclear weapons. But we should take every action to lower the dangers, and I think it can be done."

Early entrepreneurship days

Perry was born in Vandergrift, Pennsylvania, in 1927, the year that Charles Lindbergh completed the first solo flight across the Atlantic.

As a child, Perry fell in love with math. Math for him represented analytical discipline and the beauty of overcoming challenge. By solving math problems, one can master not only numerical problems, but other seemingly all-too difficult challenges. The key, as Perry discovered, was breaking down the larger problem into smaller parts. This evolved complexity into simplicity, which is more easily understood. Perry went on to cultivate this problem-solving mindset the rest of his life.

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After his military service, Perry received his B.S. (1949) and M.A. (1950) degrees from Stanford, and a Ph.D. in mathematics from Pennsylvania State University in 1957. He chose a career in defense electronics, and became one of the Silicon Valley’s early entrepreneurs, founding a company that pioneered digital technologies to analyze the Soviet nuclear missile arsenal. And so, he was often asked to counsel the federal government on national security.

In October 1962 during the Cuban missile crisis, Perry received an urgent request from the U.S. government to help analyze U-2 photos of the Soviet installation of nuclear-armed missiles in Cuba. Perry later recollected that he thought the world could end during that crisis, and that those days might well be his last.

From 1977 to 1981 during the Carter administration, Perry served as the Pentagon’s undersecretary of defense for research and engineering, where he oversaw weapon systems and research. After leaving the Pentagon in 1981 to work in the private sector, Perry became a Stanford engineering professor and a co-director of the Preventive Defense Project at Stanford's Center for International Security and Cooperation (CISAC).

He was the co-director of CISAC from 1988 to 1993. Today, he is the Michael and Barbara Berberian Professor emeritus at Stanford, with a joint appointment at the Freeman Spogli Institute for International Studies and the School of Engineering. He is also a senior fellow at the Hoover Institution.

In 1994, President Bill Clinton tapped Perry to become the 19th U.S. Secretary of Defense. However, it was not so easy for the White House to recruit him.

Perry treasured his privacy so much that he originally turned down the job of defense secretary. Only when Clinton and Al Gore assured him that his family’s privacy could be maintained, he finally accepted the offer. With the Cold War having ended a fear years earlier, he found it would become a historic time to serve as America’s defense secretary.

Years later he recalled standing with his Russian and Ukrainian counterparts as their teams destroyed missile silos in the former Soviet Union. By the end of the 1980s, Perry thought the world had survived the horrific prospect of nuclear annihilation – and that it was behind everyone, left in the ashes of the Cold War.

Not so fast. Welcome to 2017.

Beyond doomsday

Today, Perry believes, the world is arguably more dangerous than ever before. His view is supported by The Bulletin of Atomic Scientists, which announced in January 2017 that the Doomsday clock now stands at two-and-a-half minutes to midnight, suggesting that existential threats now pose a greater danger to humanity than they have at any time since the height of the Cold War.

In fact, in 2016, Perry warned that the Doomsday clock should stand at five minutes to midnight for nuclear war – but only one minute to midnight for the threat of nuclear terrorism. He said during that press conference that the clock now issued a “more dangerous, more ominous forecast than two thirds of the years during the Cold War.”

As a result, Perry’s profile has risen higher than ever as the world confronts increasingly unsettling nuclear threats like a war between the U.S. and North Korea, reckless nuclear rhetoric by state leaders, and the possibility that terrorists may use nukes.

On North Korea in particular, Perry has urged a return to deterrence on the part of the United States:

“The threat to use nuclear weapons has always been tied to deterrence or extended deterrence; historical U.S. policy is that the use of nuclear weapons would only be in response to the first use of nuclear weapons against the United States or an ally covered by our extended deterrence,” he said in a statement.

With North Korea, Perry notes that the U.S. should not make empty threats, because empty threats weaken America’s credibility and reduce the ability to actually take strong action. “As Theodore Roosevelt said, ‘Speak softly but carry a big stick,’” he said.

During the early Cold War, he said, when the Soviets used “shrill” language, U.S. presidents like Eisenhower merely responded in tempered, moderate tones. “Just as in those tense times, today’s crisis also calls for measured language,” Perry said.

On top of this, Perry said the U.S. and Russians seem to be “sleepwalking into this new nuclear arms race,” and that while a new Cold War and arms race may look different than the prior one in U.S.-Soviet history, they are both dangerous and “totally unnecessary.”

Whether on the North Korean peninsula or elsewhere, a miscalculation could be catastrophic, Perry warns. That’s one reason he joined other former "Cold Warriors" like George Schulz, Henry Kissinger and Sam Nunn to write an op-ed in the Wall Street Journal in 2007. They argued that the goal of U.S. nuclear policy should be not merely the reduction and control of atomic arms, but the ultimate elimination of all nuclear weapons everywhere.

What type of world does Perry dream about in his brightest visions? One without nuclear weapons. He believes collective humanity must “delegitimize” nuclear war as an acceptable risk of modern civilization. A safer world, one that requires great purpose, persistence, and patience to make a reality, is possible, if people understand the threats and take action to reduce them, Perry has said.

“This global threat requires unified global action,” Perry wrote in July 2017 in support of a new United Nations treaty banning the use of nuclear weapons.

Education and knowledge – that’s how Perry believes humanity can safely evolve past its nuclear phase.

MEDIA CONTACT:

Clifton B. Parker, Center for International Security and Cooperation: (650) 725-6488, cbparker@stanford.edu

On June 2, 2017, the 2017 U.S.-Japan Forum was held at Bechtel Conference Center at Stanford University.  The forum discussed three main topics: growth strategy; populism, globalization, and social equality; and technology innovation.

A summary report, full list of panelists, topics addressed and conference agenda can be viewed here.

Sometimes a straightforward explanation and an apology for what went wrong in the hospital goes a long way toward preventing medical malpractice litigation and improving patient safety.

That’s what Michelle Mello, JD, PhD, and her colleagues found in a study published Oct. 2 in Health Affairs.

Mello, a professor of health research and policy and of law at Stanford University, is the lead author of the study. The senior author is Kenneth Sands, former senior vice president at Beth Israel Deaconess Medical Center.

Medical injuries are a leading cause of death in the United States. The lawsuits they spawn are also a major concern for physicians and health-care facilities. So hospital risk managers and liability insurers are experimenting with new approaches to resolving these disputes that channel them away from litigation.

The focus is on meeting patients’ needs without requiring them to sue. Hospitals disclose accidents to patients, investigate and explain why they occurred, apologize and, in cases in which the harm was due to a medical error, offer compensation and reassurance that steps will be taken to keep it from happening again.

Positive results

The study reports on the outcome of a so-called communication-and-resolution program at two large Massachusetts hospital systems. Mello and her co-authors found that the program not only yielded positive results in terms of liability costs but also led to significant patient safety improvements.

“In these programs, hospitals scrutinize every serious harm event to answer the question, ‘What can we learn?’” Mello said. “Traditionally, a risk manager’s focus has been on the patients who complain about the care or threaten to sue. But every patient deserves to know that what happened to them is being taken seriously.”

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Despite concerns that telling patients about errors and proactively offering compensation could cause liability costs to skyrocket, of the 989 adverse events reviewed for the study from 2013 to 2015, only 5 percent led to malpractice claims or lawsuits. And when the program did lead to compensation, the median payment was $75,000. By comparison, the median payment nationwide in 2015 when plaintiffs prevailed in malpractice lawsuits was about $225,000, Mello noted.

“Our findings suggest that communication-and-resolution programs will not lead to higher liability costs when hospitals adhere to their commitment to offer compensation proactively,” the authors wrote.

Pilot program

The authors focused on a program called CARe — Communication, Apology and Resolution — at six Massachusetts hospitals: Beth Israel Deaconess Medical Center and Baystate Medical Center, and two of each center’s community hospitals.

The hospitals demonstrated good adherence to the program protocol, the authors found. Physicians were supportive of the approach but did ask for better communication about the program and what was happening with their patients.

The low percentage of events that led to litigation should reassure hospitals concerned about the risks of being honest with patients, the authors wrote. A likely explanation, according to Mello, is that explaining why adverse events occurred defused patients’ anger. About three-quarters of the time, adverse events were not actually due to error, the study said. Rather, malpractice claims frequently arise when plaintiffs perceive that the health care providers communicated poorly or attempted to cover up negligence, the authors noted.

“Given the rarity with which communication-and-resolution events resulted in settlements, it is reasonable to wonder whether the programs are worth the time they require,” the authors wrote, “but risk managers in our study thought they were. By providing explanations and expressions of sympathy for harms not arising from negligence, communication-and-resolution programs may avert lawsuits springing from misunderstanding.”

Objectives and improved safety

The CARe objectives are to improve transparency surrounding events, improve patient safety, reduce lawsuits and support clinicians in disclosing error or injury.

Medical events were bumped to a CARe evaluation if they met a severity threshold of either causing permanent or temporary harm that led to an extended hospitalization, required an invasive procedure or led to at least three outpatient visits.

Of the 989 total events studied by the authors, 60 of them entered the CARe program because the hospital received notice that the patient intended to sue. Another 929 entered the program when an adverse event was reported that allegedly exceeded the severity threshold, or that met other criteria.

The protocol called for compensation to be proactively offered whenever a violation of the standard of care caused serious harm. Only 9 percent of cases met these criteria. The largest payment made was $2 million. In 181 events, in which compensation criteria weren’t met, hospitals offered to waive medical bills or made other modest gestures, like giving the patients meal vouchers and gift cards. About three-quarters of injuries didn’t qualify for compensation because the standard of care was judged to have been met — a proportion that is consistent with prior studies of medical injuries. About a third of the injuries weren’t caused by the medical care: For example, a patient contracted an infection in the hospital but died from other causes.

“These programs are usually talked about as a way to resolve cases of medical error, but what they do more often is encourage communication with patients about non-error events — as well as systematic evaluation of each event for patient-safety lessons,” Mello said.

The authors also noted that communication-and-resolution programs “can help hospitals foster a culture of transparency by supporting clinicians in making disclosures.”

The safety interventions identified in the CARe investigations included new labeling for high-risk medications, color-coded socks for patients at risk for falls, radio frequency identification tags for surgical sponges, improved interpreter services, improvements for managing the selection of implantables after surgery, and a multidisciplinary checklist for breech deliveries.

Other authors of the study are affiliated with Harvard, Tufts, Baystate Medical Center, and Beth Israel Deaconess Medical Center.