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Disclosure is a formal process involving open discussion between a patient/family and members of the 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 as well as promotes healing for the patients/families and providers involved. It generally occurs in two broad stages (initial and post-analysis) recognizing that it 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

Recommended strategies

Before an incident:  confirm organizational processes that 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 the 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

After an incident: 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
  • Ensure to:
    • 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

After an incident:  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