3. Disclosure

In this lesson, we focus on the process of disclosing an adverse event including: why you should disclose, how to disclose, and the role disclosure plays in a just culture.

(To read along click here.)

Disclosure is the Norm in Canada

For healthcare organizations across Canada, providing disclosure to patients and their families when an adverse event occurs is the norm. It is considered to be the correct response for healthcare providers from a legal, ethical, moral, and personal point of view when harm comes from healthcare delivery.

This idea is supported in a number ways:

• A number of Canadian provinces, including Ontario, have disclosure legislation.
• Most healthcare organizations have policies related to disclosure.
• There are a number of resources available to help healthcare providers prepare for the disclosure process, including the Canadian Patient Safety Institute’s Disclosure Guidelines.
• Organizations such as The Canadian Nurses Association and The Canadian Medical Protective Association support disclosure as best practice (see here and here).

Stages of Disclosure

The Canadian Patient Safety Institute describes disclosure as “a dialogue over time.” In their Disclosure Guidelines, they suggest thinking of disclosure as occurring in two broad stages:

The first stage, initial disclosure, should take place as soon as possible after the adverse event occurs. During initial disclosure the main priority is the immediate and ongoing welfare of the patient. A decision needs to be made about who will be present at the disclosure, and when and where the discussion will take place.

The second stage, post-analysis disclosure, lets the patient or family know any additional facts about why harm occurred, and any changes that have been made to prevent it from occurring again. It’s important to ensure that the appropriate people are present at this disclosure. Most hospitals have patient relations teams to help mediate these meetings.

How to Disclose

Proper disclosure of an adverse event contributes to healing for patients and families, and healthcare providers themselves.

Because every situation is different, it’s difficult to provide a standard checklist of how to disclose to patients and families. Each disclosure needs to be tailored to the people involved and the event itself. But here is some general advice:

• Disclose in a timely manner, as close to the event as possible
• Disclose in a private setting
• Use language that is easily understood
• Speak in a way that respects cultural sensitivities
• Tell the patient or family the facts about what happened
• Explain what will be be done next:
  • If there’s harm to the patient, how you’re going to fix that harm, if possible
  • How the adverse event is going to be reviewed, and who will be involved in the review process
  • How that review is going to be undertaken, and how the patient or family can be included in that review
  • That you’re going to get back to them after you’ve done a review to share what was done and what was learned
  • The steps that will be taken (recommendations or changes) based on what was learned
• Encourage a two-way conversation, leaving space for questions. Ask, “What do you need to know?”
• Be prepared for an emotional response. This is a natural part of the disclosure process. Listen to what’s said, and try not to respond defensively.

Proper Disclosure Supports a Just Culture

Disclosure promotes patient safety, not only because it contributes to healing after an event, but also because it shows leadership and commitment to approaching harm in a systematic way when it occurs. It promotes transparency, and a just culture.

When healthcare organizations in Canada are functioning at their best, they use a framework of just culture, balancing two different needs that develop when adverse events happen:

• the need for an open and honest work environment where adverse events are proactively reported,
• the need for a culture of high quality learning.

In a just culture, it’s understood that most adverse events occur, not only because of individual healthcare providers, but also because of problems at a system level. An organization is responsible to both its employees and its patients. And although employees are held responsible for the quality of their choices, the focus is not on punishment, but on understanding what went wrong at a system level, and making changes to prevent an adverse event from occurring again. It could also involve providing additional training for an employee if it would prevent errors from happening in the future.

In rare cases, some errors do call for some type of discipline. But a just culture tries to find the balance between extreme punishment and complete blamelessness at all times.