We have so far explored the benefits and the challenges of patient safety incident disclosure. Here we will take a look at the practical aspects of the disclosure process. Different experts have tried to break the process down to its basic components. For example, Harvard Hospitals, in a consensus statement titled When things go wrong: responding to adverse events, identified five components of disclosure communications which are:
- Telling what happened
- Taking responsibility
- Expressing regret
- Explaining what will done top prevent similar future occurrences.
Robert Truog and colleagues, in their book Talking with Patients and Families about Medical Error, also identified the five core priorities that guide the disclosure process. The authors asserted that these factors, represented by the acronym TRACK, ‘help rebuild broken relationships after error’, and they are:
Rick Iedema and colleagues explored the process of planning for a disclosure meeting in paper titled Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study. Apart from ensuring that patients have access to an internal complaints mechanism to activate the disclosure process, the best practice principles they identified are: to provide information about open disclosure to the patient ‘in a language he or she understands; to explain the purpose and processes of open disclosure’; and to decide ‘the timing and location of the first face to face open disclosure meeting…in dialogue with the patient’. They also added that the patient should be consulted about which healthcare workers should attend the open disclosure meeting, and they may also nominate an open disclosure support person to represent their interests at the meeting.
In describing the practical steps in carrying out disclosure conversations, The Harvard consensus statement advised physicians to acknowledge the pain and suffering of the family members, and to express empathy and compassion to them. Whilst they advocated ‘timely, plausible and coherent explanations‘, they nevertheless cautioned against speculation and premature explanations before all the facts of the incident are known. They also advised that the discussions should be collaborative and not dominated by one side, and that the physicians should avoid the use of medical jargon or oversimplification of ‘the clinical reality’ because these may cause offence and make the family feel disrespected.
Perhaps most importantly, the Harvard consensus statement recommended that ‘a plan for future meetings should be explicitly discussed’ after the initial meeting. This stressed the point that disclosure is not a one-off event but an on-going process. This was also the opinion of Sigall Bell and colleagues in their paper titled Improving the patient, family, and clinician experience after harmful events: the “when things go wrong” curriculum. There, they emphasised that ‘disclosure should not be a singular or solitary event’ but ‘a series of interactions and family meetings that follows a three-step process which consists of the following:
- Acknowledgement during the first disclosure
- Data gathering
- Eventual full disclosure
In preparation for the disclosure meeting, Bell and colleagues highlighted the disclosure responsibilities of clinicians which are to acknowledge the event; to ‘provide accurate and timely information’; to ‘assure the patient/family that the hospital will fully look into the event to determine the root causes; to ‘reassure patients that they will be supported and cared for throughout the process’; and when appropriate, ‘to apologise to the patient and the family as soon as ‘data analysis is complete’. They also made the following recommendations to guide clinicians during the disclosure meeting:
- To hold the meeting in a quiet and private location
- To ‘turn off or sign out your beeper‘
- To ‘choose your words carefully’
- To ‘present the facts as they are known at the time’
- To ‘listen actively
- To ‘allow for silence‘
- To ‘be human‘
In their own framework for disclosing mistakes, Wu and colleagues suggested the following:
- To break the bad news ‘in a way that minimises distress‘.
- To ‘begin by stating simply that he or she has made a mistake‘
- To be prepared for anger as the response by the patient of family
- To ‘describe the decisions that were made, including those in which the patient participated’
- To describe ‘the course of events…in detail, using nontechnical language’
- To state ‘the nature of the mistake, consequences, and corrective action taken or to be undertaken’
- To ‘express personal regret and apologize for the mistake’
- To ‘elicit questions or concerns from the patient and address them’
In the next post, we will review the downsides of patient safety incident disclosure.