Disclosure of patient safety incidents

• An incident is an event or circumstance that could have, or did result, in unnecessary harm to a patient. Incidents are grouped into one of three categories based on the level of harm:¹
• Harmful incident: A patient safety incident that resulted in harm to the patient.
• No harm incident: A patient safety incident that reached a patient but no discernable harm resulted.
• Near miss: A patient safety incident that did not reach the patient.¹
• Disclosure is the process by which a patient safety 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 and incident reporting should occur following an incident that affects patient safety or management.
• Using 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.^2,3
• Disclosure is a component of patient and person-centered 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^4,5

• Within the limits of MRT knowledge, authority, and responsibility, MRTs have an ethical obligation to be open and honest when communicating with patients and/or their families.¹
• MRTs should be familiar with the incident recording and disclosure policies and procedures at their facility and ensure compliance with those requirements.
• The CAMRT Member Code of Ethics and Professional Conduct requires MRTs to treat patients with respect and to involve patients in their own care.⁶
  • Disclosure of adverse events is a significant element of this philosophy.

• The process of disclosing errors requires courage, composure, communication skills, and a belief that the patient is entitled to know the truth.⁷
  • Documentation at every step of the process is important to maintain a factual basis for the ongoing analysis and improvement process that follows disclosure.¹

To disclose or not

• In keeping an open, and patient and person-centered approach to care, 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 takes 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. It enables the patient and family to proactively monitor the patient’s potential symptoms/indicators associated with the event.⁵

What to disclose

• According to patients, who have clinical, emotional and information needs, the following information should be divulged in the disclosure process^8–10:
  • the facts of the incident (not speculation or judgment/blame);
  • steps taken to minimize harm;
  • expression of regret for what has occurred (see “Dimension of apology” section below for important considerations); and
  • steps that will be taken to prevent further harm or similar events in the future.
• Throughout disclosure, emphasis is placed on the patient’s understanding, and that an appropriate opportunity for questions and answers is given.¹
• The Canadian Patient Safety Institute (CPSI) Disclosure Guidelines recommend that the disclosure discussion with the patient and/or family also include¹:
  • 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; and
  • 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

• In most provinces/territories in Canada, legislation exists that expressly prevents apologies from being considered admissions of fault or liability. MRTs should be aware of such legislation within their own province/territory.
• Offering an apology as part of disclosure is consistent with patient and person-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.^11–13
• Despite widely expressed concern that an apology implies an admission of negligence or legal responsibility, there is little evidence to support this view.¹⁴

Who should disclose?

• Disclosure has been shown to be most beneficial when the person disclosing is¹⁵:
  • known to the patient and familiar with the incident, and
  • willing to keep a relationship with the patient.
  • A team-based approach is beneficial to both the healthcare professionals and the patient.¹
• MRTs should be familiar with disclosure policies and procedures at their own facility, since these may contain a description of 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.¹
  • The clinical and psychological condition of the patient is always taken into account when deciding on the appropriate course of action for disclosure.¹⁵
• 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 questions and address concern.
• Following initial disclosure, appropriate information continues to be shared with the patient as new discoveries from the investigation come to light.¹⁵
  • 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.