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Disclosure


Maintaining trust

What is disclosure?


  • A process by which harm from healthcare delivery is communicated to the patient or the patient's family, or both.
  • Patients and providers both experience considerable emotional distress when these situations arise, making disclosure discussions particularly difficult and necessitating advanced communication skills.

Healthcare providers have an ethical, professional, and legal obligation to disclose harm from healthcare delivery to patients.

Case: Patient with cancer suffers from pain
Close up of nurse with syringe (patient in background)

Background

An adult patient with cancer is suffering from severe pain.

As the first-year resident caring for the patient, you inadvertently order 10 times the intended dose of an opioid medication due to a misplaced decimal point and the presence of a trailing zero.

The nurse administers the dose as ordered and the patient becomes very drowsy, apneic, requires an opioid antagonist, and temporary respiratory support.

Fortunately the patient makes a full recovery.

Think about it

  • Would you consider this to be a harmful incident (accident in Québec)?
  • Should the patient be told of the reason for the clinical emergency?
  • Who should disclose this to the patient?
  • Should the nurse be involved in the disclosure discussion?
  • What would you say if you were disclosing this to the patient?
  • Would you apologize?

Outcome

The ordering and administration of the wrong dose of the narcotic constitute a harmful incident because the patient was harmed by healthcare delivery (i.e. the patient required additional care and monitoring), and the harm was not due to an inherent risk of the prescribed treatment.

This complication should be disclosed to the patient.

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Following harm from healthcare delivery, patients have clinical, emotional, and information needs. Research confirms that following an unexpected clinical outcome patients want:

  • an acknowledgement that something has gone wrong;
  • the facts that are known about what happened;
  • an understanding of the recommended next steps in clinical care;
  • a genuine expression of concern and regret;
  • reassurance that appropriate steps, if possible, are being taken to prevent a similar occurrence from happening again to themselves and to others.

When to disclose

Different terminologies related to harm and disclosure may be used by different organizations and jurisdictions.

To learn more about the 3 terminology conventions commonly used in Canada, review the section Understanding harm.


When to disclose if using "Adverse event" terminology

(Canadian Disclosure Guidelines - CPSI 2008)

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To learn more about disclosure guidelines if using "adverse event" terminology, click on each box in the diagram.

If analysis indicates harm resulted from...

  • Natural progression of the underlying disease

  • Healthcare delivery = Adverse event

Natural progression of the underlying disease

Discuss with patient

Other types of events

  • Event reached patient

    • Potential for harm

    • No potential for harm

  • Close call (did not reach patient)



When to disclose if using "Patient safety incident" terminology

(WHO ICSP, Canadian Disclosure Guidelines - CPSI 2011)

(Read as text only)
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To learn more about disclosure guidelines if using "patient safety incident" terminology, click on each box in the diagram.

If incident analysis indicates the harm resulted from...

  • Natural progression of the underlying disease

  • Healthcare delivery

    • Inherent risk of investigation or treatment

    • Harmful incident

Other types of patient safety incidents

  • No harm incident
    (reached the patient)

  • Near miss
    (Did not reach the patient)


Disclosure requirements in Québec

The Act Respecting Health Services and Social Services in Québec defines the terms accident and incident, and clarifies the need for disclosure of such events to patients.

The Code of Ethics of Physicians in Québec states that "A physician must, as soon as possible, inform his patient or the latter's legal representative of an accident or complication which is likely to have or which has had a significant impact on his state of health or personal integrity."

Accident

In Québec law (Act Respecting Health Services and Social Services), an accident is "an action or situation where a risk event occurs which has or could have consequences for the state of health or welfare of the user, a personnel member, a professional involved, or a third person."

Any accident should be disclosed to the patient.

Incident

In Québec law (Act Respecting Health Services and Social Services), an incident is "an action or situation that does not have consequences for the state of health or the welfare of the user, a personnel member, a professional involved or a third person, but the outcome of which is unusual and could have had consequences under different circumstances."

An incident, as the term is defined in Québec, may require disclosure if:
  • the incident reached the patient but there were no consequences. Generally such incidents should be disclosed to patients.
  • the incident did not reach the patient (i.e. the incident was caught in time) but the potential for harm existed. The patient should be informed of the incident if there is a similar, ongoing safety risk for that patient, or if the patient is aware of the incident and an explanation will allay concern and promote trust.

In Québec government-run institutions such as hospitals, the law requires the completion of a report in the prescribed format, for both accidents and incidents. The report is kept with the patient's medical record.

It is advisable to alert the patient to the incident, the report, and any subsequent preventive measures put in place. This will reduce the likelihood of misunderstanding or mistrust if the patient views the medical record and report in the future.



Disclosure requirements in Québec

Consequence: An outcome that negatively affects the patient's health and quality of life.
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To learn more about disclosure requirements in Québec, click on each box in the diagram.

If the consequence is found to be due to...

  • Natural progression of the underlying disease

  • Accident

In the case of an event that...

  • Reached the patient, but no consequence

  • Did not reach the patient, so no consequence