Disclosure of Adverse Events and Errors

According to the American Medical Association’s Code of Medical Ethics, in situations involving patient harm potentially resulting from a physician’s mistake or judgment, physicians are required to discuss with the patient all the pertinent information around the event in order to ensure full understanding. This enables informed decision-making for future care (Fondahn et al, 2016). As such, the basis for disclosure of adverse events and errors stems from this ethical responsibility between providers and patients and is in alignment with the principles of doing good (beneficence) and preventing harm (nonmaleficence).

Unfortunately, disclosure does not always occur. This may be due to a lack of training for professionals, lack of processes around disclosure, concern for the loss of reputation among colleagues and patients, and fear of litigation. Literature has shown that after an adverse event occurs, patients want to know and understand what happened. They want an admission of responsibility along with what is being done to prevent future occurrences. In addition, research has shown that disclosure is associated with a reduction in the number of malpractice suits as well as the average settlement amount (ACOG, 2016). The following article describes disclosure in more detail.

When to Disclose?

Disclosure is appropriate in circumstances resulting in temporary or permanent harm, transfer to a higher level of care, surgery, or other interventions being required. Another way of determining when disclosure is appropriate is by framing it from the perspective of- if this were something that happened to you or someone close to you, would you want to know about it? (Fondahn et al, 2016).

Who Should be Involved?

If multiple care providers are involved, the discussion should occur among the team prior to disclosure regarding what information will be discussed. Some organizations offer coaching programs to assist with this. Risk management and patient safety specialists can also help. Typically the attending physician involved in the event leads the conversation. Other staff that may step in include nurses, other providers, or leadership.

What do Patients Want to Know?

General acknowledgment that the event/error occurred
Apology for having to go through the event
An explanation for what happened and why
Understanding of the clinical implications
How this situation will be prevented from recurring in the future (Fondahn et al, 2016)

Acknowledgment and Apology

To begin with, it’s important that the event is acknowledged. There is nothing worse than the silence that can occur after an untoward outcome. Having those early, crucial conversations and supporting patients and families are key. Successful disclosure involves acknowledging what has happened, offering an apology when appropriate, along with expressing sympathy for the suffering endured by both the patient and family.

The appropriateness of offering an apology is dependent on the case. Input from hospital risk management and the provider’s liability carrier should be sought in these instances (ACOG, 2016).

An explanation for What Happened and Clinical Implications

Only the facts should be shared with the patient. It is important to leave out any speculations or hypotheses of event causes if unknown. In addition, explaining what happened in a simple manner and avoiding medical jargon is helpful. If at all possible, an investigation of the event is done before the disclosure in order to provide the most accurate information to the patient. If the investigation is ongoing, the patient can be informed that as more information is obtained, they will be notified.

This conversation should be timely, occurring as soon as possible after the event. Several conversations may be needed, depending on the situation and the information available at the time. The key to effective communication is active listening, acknowledging patient and family concerns, including plans for managing the current medical care, and identifying a point person for future contact if needed (Fondahn et al, 2016) (ACOG, 2016).

Steps to Prevent Recurrences

Patients want to know that what happened to them will not happen to other patients. They often do not know what quality and safety programs are in place, including (but not limited to): protocols, guidelines, root cause analysis, apparent cause analysis, peer review, safety event investigations, and education. No matter what level of investigation is performed, from safety event review to root cause analysis, it is important that any opportunities for improvement are addressed and processes put into place to prevent any further patient harm.

Sharing that event review has occurred and changes were implemented with patients and families will aid in their understanding of how organizations work toward safe, high-quality care and preventing event recurrences (ACOG, 2016).

What Organizations Can Do to Help

There are a number of things that organizations can do to help. To begin with, developing policies on the management of adverse events. This may include plans around crisis management, team response, and communication. Additional suggestions include providing coaching programs around disclosure and support programs for healthcare providers as second victims (ACOG, 2016).

Summary

When an adverse event or error occurs, disclosure involves sharing information about the event with patients in an effort to promote transparency, trust, accountability, patient autonomy, and informed consent. Patients want to know and understand what happened, along with what is being done to prevent future recurrences. It’s the right thing to do.

In addition, organizations can help to support staff in disclosure and personal recovery. This can be done by setting up policies and programs that provide the necessary training and tools for success, and by providing resources for mental/emotional/psychological recovery.

References
American College of Obstetricians and Gynecologists. Committee opinion no. 681: Disclosure and discussion of adverse events. (2016). Obstetrics & Gynecology, 128(6), e257–e261. https://doi.org/10.1097/aog.0000000000001816

Fondahn, E., Fer, T. M. D., Lane, M., & Vannucci, A. (2016). Washington Manual of Patient Safety and Quality Improvement. Lippincott Williams & Wilkins.