+ Importance of disclosure
- Disclosure is the process by which a harmful incident or adverse event is communicated to the patient by healthcare providers. The occurrence of an incident does not necessarily indicate substandard care or negligence.1
- Disclosure accompanies incident reporting following an incident that affects patient safety or management
- The term disclosure in communications with patients does not imply blame or fault of the healthcare provider.1
- When staff members come forward, acknowledge an incident, and take the necessary corrective actions, the overall trauma associated with the incident can be greatly reduced for patients, caregivers and professionals.2
- Disclosure is a component of patient and family-centred care and addressing incidents provides an opportunity to:1
- Mitigate anxiety and fear that information is being withheld
- Assist patients (and their families) in their understanding of an incident
- Be respectful of patient autonomy in decision making
- Effective communication and appropriate provision of care following a patient safety incident are key factors in influencing a patient’s decision about whether to initiate legal action.1
+ Ethical obligation
- MRTs have an ethical obligation to be open and honest when communicating with patients and/or their families.1
- The CAMRT Code of Ethics requires MRTs to treat patients with respect and aspire to keep them involved in all health decision making.3
- Disclosure of adverse events is a significant element of this philosophy
+ Disclosure in practice
- The process of disclosing errors requires courage, composure, communication skills and a belief that the patient is entitled to know the truth.4
To disclose or not
- Disclosure of an incident is made to the patient whenever there is harm or potential for harm.1
- When there is uncertainty about whether harm has occurred, it is recommended that disclosure take place
- When an incident takes place and there is no apparent harm to the patient, but the potential for harm remains, disclosure supports an open, transparent and trusting relationship with the patient, and enables the patient and family to proactively monitor his or her condition5
- A rule of thumb in deciding whether to disclose an incident that did not result in harm to the patient is the consideration about whether a reasonable person would want to know about the event in the circumstances
- A discussion of harm is appropriate whenever harm occurs (due to disease process, known risks or otherwise), in keeping with a patient and family-centred and open approach to care.1
What to disclose
- According to patients, the following information should be divulged in the disclosure process:6,7
- The facts of the incident (not speculation or judgment/blame)8
- Steps taken to minimize harm
- Expression of regret for what has occurred (see “Dimension of apology” section below for important considerations)
- Steps that will be taken to prevent further harm or similar events in the future
- Throughout disclosure, emphasis is placed on patient understanding, and appropriate opportunity for questions and answers is given.9
- The Canadian Patient Safety Institute (CPSI) Disclosure Guidelines recommend that the disclosure discussion with the patient and/or family also include:1
- An overview of the process that will follow, including appropriate timelines and what a patient can expect to learn from analysis
- An offer of future meetings
- An offer of practical and emotional support
- The CPSI recognizes that elements of the disclosure process beyond the initial phase may be subject to local and/or provincial legislation. As a result, facility leadership/management may need to make decisions based not only on the needs of the patient but also the application of legislation.1
Dimension of apology
- Offering an apology as part of disclosure is consistent with patient and family-centered care.1
- Reports show that when patients believe they have received a sincere apology, they feel respected and validated and often trust is restored
- Despite widely expressed concern that an apology implies an admission of negligence or legal responsibility, there is little evidence to support this view.10
- In most provinces in Canada, legislation exists which expressly prevents apologies from being considered admissions of fault or liability.11-20
Who should disclose?
- Disclosure has been shown to be most beneficial when the person disclosing is:5
- Known to the patient and familiar with the incident
- Willing to keep a relationship with the patient
- Management, in consultation with primary care providers, determines what information is disclosed, as well as who participates in the disclosure.
- All relevant healthcare professionals are notified/consulted8
- MRTs should be familiar with disclosure policy at their own facility, as this may contain description as to who should be involved in disclosure
- As the results of analysis of the incident emerge, facility leadership and management usually take a larger role.1
- MRTs involved in a patient safety incident will have continued involvement through interactions with professionals at their own facility and are encouraged to keep informed of the communications and the progress of the analysis.
When to disclose
- Once the patient has received the necessary care and management following the patient safety incident, a priority is placed on addressing the incident with the patient (as well as family, if applicable) as soon as possible.21
- The clinical and psychological condition of the patient is always taken into account when deciding on the appropriate course of action for disclosure5
- An initial disclosure is preferably made within two days of the event.1
- A meeting with the patient/family is held to provide information, answer question and address concerns21
- Following initial disclosure, information continues to be shared with the patient as new discoveries from the investigation come to light.5
- New facts that would have otherwise been on the patient’s chart are shared with the patient and/or family
- Actions being proposed to try to prevent a similar event from happening in the future are shared with the patient and/or family
- Non-factual information, such as opinions and speculation, that emerge during investigatory meetings are not shared with patients
- Documentation at every step of the way is important to maintain a factual basis for the ongoing analysis and improvement process that follows disclosure.1
- Notes from all meetings containing all the facts and decisions make up the basis for quality documentation, including details of:1
- Time, place and date of meetings
- List of attendees
- Facts discussed
- Offers of assistance and responses
- Questions raised with answers given
- Agreed steps for follow-up
- Key contact people with details
- Canadian Patient Safety Institute, Canadian Disclosure Guidelines: Being open with patients and families 2011: Available at: http://www.patientsafetyinstitute.ca/English/toolsResources/disclosure/Documents/CPSI%20Canadian%20Disclosure%20Guidelines.pdf. Accessed April 4, 2012.
- Vincent C. Understanding and responding to adverse events. N Engl J Med 2003;348(11):1051-1056.
- Canadian Association of Medical Radiation Technologists. Code of Ethics. Available at: http://www.camrt.ca/abouttheprofession/codeofethics/. Accessed April 3, 2012.
- Boyle D, O’Connell D, Platt FW, Albert RK. Disclosing errors and adverse events in the intensive care unit. Crit Care Med 2006,34(5):1532-1537.
- Health Quality Council of Alberta. Disclosure of Harm to Patients and Families. Provincial Framework, July 2006. Available at: http://publications.hqca.ca/preview/62. Accessed April 4, 2012.
- Gallagher TH, Waterman AD, Ebers AG, et al. Patients’ and physicians attitudes regarding the disclosure of medical errors. JAMA 2003;289(8):1001-1007.
- Iedema R, Sorensen R, Manias E, et al. Patients' and Family Members' Experiences of Open Disclosure Following Adverse Events. Int J Qual Health Care 2008;20(6):421-432.
- Health Quality Council of Alberta. Checklist for disclosure team discussion. Available at: http://www.hqca.ca/assets/pdf/Disclosure/HQCA_checklist_FINAL.pdf. Accessed April 4, 2012.
- Nova Scotia Health. Ask, Talk, Listen: Tips for communicating with patients and their families. Available at: http://www.gov.ns.ca/health/health_care_safety/factsheet_tips_comm_patients_families.pdf. Accessed April 4, 2012.
- Wilson, J, McCaffrey, R. Disclosure of medical errors to patients. MEDSURG Nursing 2005;14(5):319-323.
- Yukon. Apology Act, 2007. Available at: http://www.leg.bc.ca/38th2nd/3rd_read/gov16-3.htm. Accessed April 4, 2012.
- British Columbia. Apology Act, 2006. Available at: http://www.leg.bc.ca/38th2nd/3rd_read/gov16-3.htm. Accessed April 4, 2012.
- Alberta. Evidence Amendment Act, 2008. Available at: http://www.assembly.ab.ca/ISYS/LADDAR_files/docs/bills/bill/legislature_27/ session_1/20080414_bill-030.pdf. Accessed April 4, 2012.
- Saskatchewan. The Evidence Act, 2006. Available at: http://www.qp.gov.sk.ca/documents/english/Statutes/Statutes/e11-2.pdf. Accessed April 4, 2012.
- Manitoba. The Apology Act, 2007. Available at: http://web2.gov.mb.ca/laws/statutes/2007/c02507e.php. Accessed April 4, 2012.
- Nunavut. Consolidation of Legal Treatment of Apologies Act, 2010. Available at: http://www.canlii.org/en/nu/laws/stat/snu-2010-c-12/latest/snu-2010-c-12.html. Accessed April 4, 2012.
- Ontario. Apology Act, 2009. Available at: http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_09a03_e.htm. Accessed April 4, 2012.
- Nova Scotia. Apology Act, 2008. Available at: http://nslegislature.ca/legc/bills/60th_2nd/3rd_read/b233.htm. Accessed April 4, 2012.
- Prince Edward Island. Health Services Act, 2011. Available at: http://www.gov.pe.ca/law/statutes/pdf/H-01-6.pdf. Accessed April 4, 2012.
- Newfoundland. An Act Respecting Apologies, 2009. Available at: http://www.assembly.nl.ca/legislation/sr/annualstatutes/2009/a10-1.c09.htm. Accessed April 4, 2012.
- Doucette E, St-Laurent J. Full Disclosure of Adverse Events to Patients and Families in the ICU: Wouldn’t You Want to Know? Presentation at CCACN Dynamics Conference, Fredericton, September 2009. Available at: http://www.caccn.ca/en/pdfs/7B%20Full%20Disclosure.pdf. Accessed April 4, 2012.