Disclosure is a formal process involving open discussion between a patient/family and members of a healthcare organization about a patient safety incident (including near misses). Disclosure provides the means for dialogue throughout the incident management process, supports patient safety improvement and promotes healing for the patients/families and providers involved.
It generally occurs in two broad stages (initial and post-analysis) and is an ongoing process in which multiple disclosure conversations occur over time.
“…It made me feel that I could trust my provider because, I mean she took responsibility… had remorse about what happened. She wasn’t defensive.” -- A family member
“I wasn’t allowed to be a part of the disclosure process, I needed to see the family of the boy who died; I needed to say: ‘I’m sorry.’ I’ll always wonder if they know how sorry I am and how it changed my practice.” -- A healthcare provider
Before an incident
Confirm that organizational processes support disclosure
- Establish guiding principles for disclosure (e.g. patient-centred healthcare, patient autonomy, honesty and transparency, patient safety, just culture, learning and improvement).
- Develop disclosure policies, procedures and tools aligned with the organization’s guiding principles, disciplinary/accountability systems, legislation, regulatory/licensing requirements, and best practices that:
- involve patients/ families and frontline staff in their development
- articulate when and where disclosure should take place and how it should be conducted
- include supports and resources available to the patient/family and healthcare providers
- provide guidance on how to deal with the media in the event of a public disclosure
- incorporate processes that address special circumstances such as multi-patient disclosures, paediatric patients or those with mental health issues, or incidents related to research
- are easily accessible to all, including frontline staff and patients/families (e.g. public site)
- are updated regularly to ensure relevance and alignment with other policies and current context
- Provide disclosure training programs and educational resources for staff and patients/families.
- Allocate resources to assist patients/families involved in patient safety incidents, ensuring they are available without delay (e.g. practical, emotional, financial).
- Allocate resources to assist staff at the frontline involved in patient safety incidents as needed, including disclosure support and coaching.
After an incident
Develop a specific disclosure plan
- After caring for the immediate needs of the patient/family and providers, develop a customized disclosure plan specific to the incident and the ongoing needs of those involved.
- If possible, conduct a pre-disclosure team huddle to determine the best approach, including:
- when the initial disclosure will occur taking into consideration patient/family readiness and preferences
- where the disclosure will take place, preferably a private area that is free of interruptions or off-site if indicated
- what information will be shared with the patient/family, including confirmation of the known undisputed facts
- who is the best person to initiate disclosure and coordinate the ongoing disclosure
- how the care providers involved in the incident will be supported
- how the patient/family will be supported and their questions/concerns addressed
- how disclosure will be documented
- Inquire with the patient/family who will attend the meeting, encourage the patient/family not to attend alone (e.g. other family members, friends, translator, spiritual support), and ask if the patient/family have preferences on who should attend or not attend from the care team.
Initiate initial disclosure
- Use language and terminology that the patient/family can easily understand.Avoid speculation or blame.
- Introduce the participants to the patient/family, including their functions and reasons for attendance.
- Acknowledge the incident or that something unexpected has happened and express apology using the words ‘I’m sorry’.
- Provide an overview of how the meeting will run and ask how the patient/family would like to participate.
- Ask about concerns and questions the patient/family would like to discuss and offer support or resources if needed.
- Share the following information:
- the currently known facts of the incident
- the steps for ensuring the ongoing care and well-being of the patient (e.g. clinical care, treatment)
- a brief overview of the incident analysis process including expected timelines and what the patient/family can expect during the process
- Offer the patient/family an opportunity to speak about their experience and ask questions.
- Ask about preferences for future involvement and information (how, when, where).
- Ask the patient/family to identify a contact person.
- Designate a key contact person from the organization who will provide regular updates.
- Provide practical and emotional support (e.g. spiritual care services, counselling, social work, family arrangements, reimbursement of expenses associated with the disclosure process).
- Document the disclosure discussion in accordance with organizational policies.Include:
- the time, place, date, the names and relationships of all attendees
- the facts presented
- offers of assistance made and the response, questions raised and the answers given
- patient/family preferences about future disclosure discussions
- plans for follow-up and key contact information for the organization and the patient/family
Continue disclosure throughout the incident management process as needed
- Continue to be engaged with the patient/family according to their preferences:
- continue to offer practical and emotional support
- transparently correct any incorrect or incomplete information that was provided in previous disclosure meetings
- provide new factual information as it becomes available
- offer a further apology which might include an acknowledgement of responsibility for what happened as appropriate and in accordance with organizational policies and applicable legislation
- describe any actions that are taken as result of the internal analysis such as system improvements in accordance with organizational policies and applicable legislation
- Continue to offer updates, and practical and emotional support for providers.
- Ensure providers maintain involvement in the disclosure process as appropriate, particularly if leadership takes on a larger role in the post analysis stage.
- Continue to document disclosure discussions per organizational policies.