Disclosure is a cornerstone of the management of patient safety incidents. The requirement to disclose harm caused to patients is now accepted as an obligation of care. There are moral and ethical reasons why harm must be disclosed to its victims, and this was highlighted by Elaine O’Connor and colleagues in their paper titled Disclosure of patient safety incidents: a comprehensive review. In this paper, they pointed out the self-evident fact that ‘patients have a right to know what has happened to them’. The moral responsibility to disclose harm was also emphasised by Nancy Berlinger in her book After Harm: Medical Error and the Ethics of Forgiveness, where she cited the theologian Dietrich Bonhoeffer on the need to see and respond to the world from ‘the perspective of those who suffer‘. Berlinger therefore urged physicians to adopt this ‘view from below‘ and appreciate adverse events from the patient’s perspective and disclose harm in that spirit. In contrast, concealing patient safety incidents and harm comes at the cost of serious consequences, as highlighted by Thomas Gallagher and Wendy Levisnon in their paper titled Disclosing harmful medical errors to patients: a time for professional action. There, they pointed out that concealment not only ‘threatens public confidence in medicine’, it also ‘ultimately undermines the quality of health care‘.
The wide benefits of disclosure for patients were explored by Albert Wu and colleagues in their paper titled To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. In this paper, they showed how disclosure enables the physician to ‘mitigate the consequences of a mistake and institute ‘timely and appropriate treatment to correct problems resulting from the mistake’. Disclosure, they added, gives the patient the requisite information to make subsequent informed decisions‘, and to stop ‘worrying needlessly about the etiology of a medical problem’. On a broader scale, Wu and colleagues suggest that disclosure helps to ‘promote trust in physicians’, and to reduce the anger and the sense of betrayal that almost inevitably arise after harm. Furthermore, they indicate that it ‘encourages the patient to take greater responsibility for his or her own care’ by the ‘acknowledgment of fallibility‘ of healthcare, and by bringing uncertainties ‘into the open’. O’Connor and colleagues also noted the practical utility of disclosure when they said that it is a necessary step for the patient to ‘allow informed consent for ongoing care‘.
The benefits of disclosure are however not restricted to patients, but extend to physicians who cause harm to them. Wu and colleagues discussed the varied ways by which doctors benefit from disclosure. At the personal and emotional level, they argued that ‘the physician may be relieved to admit the mistake’, and this enables ‘grieving about and learning from the mistake’ to start – a process that may prevent the isolation that concealment often engenders after harming patients. Furthermore, the authors pointed out that by disclosing harm, the physician ‘may earn forgiveness from the patient or family member and ‘decrease the likelihood of legal liability‘. At a deeper level, they remarked that disclosure may ‘help physicians to learn and improve their practice’; ‘help the physician accept responsibility‘ for the mistake and ‘make constructive changes in practice’; and help other physicians ‘learn vicariously‘ from the mistake.
Beyond the individual benefits to the patient and the doctor, disclosure also helps to maintain the patient-physician relationship. Illustrating this, O’Connor and colleagues pointed out that ‘good communication around an adverse event’ strengthens the relationship by preventing the damage that would result if the patient finds out about the adverse event later. They also portrayed disclosure as ‘an opportunity for forgiveness and reconciliation after an adverse event’. Disclosure also has benefits for the wider health organisation, O’Connor and colleagues noting that ‘good disclosure practice makes effective reporting and learning more likely’.
In the next blog post, we will look at the challenges of patient incident disclosure.