•What happened i.e. the adverse event
• Impact on the individual/family/support person
• Use an example and sample language.
Truthfulness: Stick to the facts
Remember that you won’t always have and don’t need to know all the answers initially. If you don’t know just tell the patient that you don’t know.
Do not speculate/surmise and no conjecture.
Provide reassurance regarding the review of the event and when further information may be available.
Agree next steps and future communications.
Timeliness:
•Timing is of the essence
•ASAP. On the day if possible.
•Dr Albert Wu’s 24 hr golden window of opportunity.
•Discuss what may influence the timing of the disclosure i.e. condition of the patient,availability of the patient, agreement of the patient, availability of their support person, availability of the most responsible clinician etc.
•Discuss timing when the adverse event becomes known after the patient is discharged using an example e.g. Missed diagnosis on scan or x-ray. How should this patient be contacted and by whom? What measures need to be in place before contacting the patient e.g. Most Responsible Physician (MRP) needs to be aware and an appointment time allocated to see MRP asap.
Clarity of communication:
- Avoid medical jargon.
- Use simple language which the patient can understand.
- Ensure understanding by asking the patient to feedback to you their understanding of what theyhave been told.
- Encourage questions.
•Definition
•Discuss the meaning of the word – contexts used
•Is an apology an admission of liability? – discussion
•Avoidance of legal terminology such as “Liability” – “Negligence”.
•Apology v expression of regret. Focus on the type of sorry required. Sorry is always appropriate when a patient has suffered harm for whatever reason. Focus on the need for empathy when apologising.
Consider the different contexts of the word “Apology”
Admission of guilt
•request for forgiveness
•admission of guilt
•regret
•confession
•act of contrition
Defence
•defence
•excuse
•explanation
•Assurance
Poor substitute
•poor substitute
•pathetic excuse
•poor example
•pretence of a
•epitome
•Discuss the 4 essential components of an apology using an example:
- Acknowledge: what it is you are apologising for- what happened, the patients experience, failures in care, error/mistake.
- Explanation: as to why or how it happened – should be factual and not speculative
- Delivery: Discusstiming -language- tone of voice – confidential, personal, respectful – dignified – sincere – empathetic - where itshould happen – who should deliver the apology?
- Reparation: Making things right – increased contact, reassurance re ongoing care – VIP treatment – consider expenses.
Ask the audience to consider what their expectations would be if they or a loved
one was involved in an adverse event?
•Acknowledgement – reassurance regarding current and ongoing care - explanation, anxpression of regret or apology – answers to questions – involvement and inclusion in
the review process – reassurance regarding how a recurrence of the event ma be avoided and measures being taken by the organisation.
Dr Lucian Leape’s “Golden Rule” – we should deliver no less to our patients than we would expect for ourselves or for a loved one.
•Discuss the impact of adverse events on staff and the importance of staff support
•Albert Wu – Concept of the second victim
•When an adverse event occurs the care of the patient and family is critical but parallel to this we must identify the second victims i.e. the staff involved and ensure that they are being supported on an ongoing basis. Also consider the impact on staff who are not involved in the incident but who are affected by the incident and also the impact on the wider organisation i.e. the third victims.
Discuss how open disclosure is an essential component in the incident
management and quality improvement process.
Incident identification, management, reporting, disclosure, review, learning and
taking measures to try to prevent a recurrence of the event are all
Essential cogs in the risk management and quality improvement wheel or cycle.
Involving patients and their families in that process.
Consider the role of the risk management department.
Discuss, using examples how open disclosure relates to all staff and not just
clinicians e.g. catering staff spill hot tea on patient, simple medication error by a
nurse or midwife, member of portering staff has an incident on way to x-ray
where patient was not secured in the chair and fell out.
Discuss the importance of team support and a multidisciplinary approach to incidents and OD.
The open disclosure process is one of the key elements of the HSE clinical
governance system. Health and social care services are required to have appropriate
accountability structures in place which ensure that open disclosure occurs and that
it is integrated with other clinical governance systems and processes including
clinicalincident reporting and management procedures, systems analysis reviews,
complaintsmanagement and privacy and confidentiality procedures.
Consider the processes/structures in place at organisation level to manage situations
when there is a conflict of opinion in relation to OD.
Stress the importance of confidentiality in relation to open disclosure discussions.
Discuss disclosure to the next of kin/support person.
Discuss and clarify the role and rights of the next of kin in relation to disclosure of information and alsodisclosure of information to persons/family members withpower of attorney and enduring powerof attorney.
Discuss the importance of reassuring the patient in relation to their ongoing
care – that they are involved in and understand their care plan going forward.
VIP treatment. Instil confidence.
Increased contact.
If they complain or pursue a legal case that they are not treated any differently.
Discuss the management of a breakdown in the patient/clinician relationship –
referralto another clinician if the breakdown is irreparable.
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A.Tysall December 2015 HSE Quality Improvement Division