Open disclosure

What is open disclosure?

Open disclosure is the “open discussion of adverse events that result in harm to a patient while receiving health care with the patient, their family and carers.” 1

What are the key principles of open disclosure?

The key principles include:

  • expression of regret
  • disclosure of a clinical incident to a patient
  • staff support and training
  • support for incompetent adults and minors
  • patient support
  • clinical governance
  • confidentiality
  • fairness.

What is the open disclosure process?

Following detection of a clinical incident the following measures should be implemented by the hospital/health service:

  • Report the clinical incident to a relevant authority, in accordance with Department of Health policy.
  • Notify the patient of the clinical incident and the facts that are known up to that point in time.
  • Undertake an investigation of the clinical incident.
  • Provide feedback to the patient.
  • Develop an agreed plan for the ongoing care of the patient.

What clinical incidents require the open disclosure process to be initiated?

As a matter of policy, patients must be informed of the probable or definite occurrence of a clinical incident that has resulted in, or is expected to result in, harm to the patient, including:

  • a defined sentinel event that is reportable to the Director, Patient Safety Directorate (refer to OD 0421/13 Clinical Incident Management (2012) Policy (external site) for WA Health)
  • a clinical incident that has, or is expected to have, a significant clinical effect on the patient and that is perceptible to either the patient or the health care team
  • a clinical incident that necessitates a change in the patient’s care
  • a clinical incident with a known risk of serious future health consequences, even if the likelihood of that risk is extremely small
  • a clinical incident that requires hospital/health service staff to provide treatment or undertake a procedure without the patient’s consent.

How long after a clinical incident should open disclosure occur?

The initial disclosure to the patient should occur as soon as possible, ideally within 24 hours of the clinical incident occurring.

The length of time to conduct the open disclosure process will depend on a number of factors, including:

  • the clinical condition, emotional and psychological state of the patient
  • the availability of reliable clinical information
  • the availability of key staff and of the patient’s relatives/carers
  • patient preference and privacy.

Who should undertake the open disclosure of a clinical incident to the patient?

When a clinical incident occurs and requires disclosure, members of the treating team should determine the most appropriate person to speak to the patient.

The person undertaking the open disclosure process should be:

  • ideally known to the patient (however it may not always be practical for a health care practitioner, who is involved in a clinical incident, to lead the open disclosure process)
  • familiar with the facts of the clinical incident and the care of the patient
  • familiar with the WA Open Disclosure Policy and have received appropriate training in the open disclosure process
  • able to communicate effectively
  • empathetic and able to offer reassurance and support to the patient
  • willing to maintain a medium to long-term relationship with the patient, as required.

Ideally, the responsible consultant/non-salaried medical practitioner as the most senior member of the team will undertake the open disclosure process.

However, each hospital/health service may delegate this responsibility to an appropriate hospital/health service manager or another member of the treating team.

Check with the local safety and quality team in your hospital/health service about the process for undertaking the open disclosure following a clinical incident.

Can I talk with the patient’s family about the clinical incident?

Discussing the clinical incident with a patient’s nominated relatives/carers/support person can only take place with the consent of the patient.

Can I apologise to a patient following a clinical incident?

Expressions of regret and admissions of liability

During the open disclosure process, a hospital/ health service may provide an apology for what has happened.

An apology or expression of regret should include

  • the words ‘I am/we are sorry’
  • known clinical facts and a discussion of ongoing care
  • an agreement to provide feedback information when available.

The Civil Liability Act 2002 (external site) defines an apology as, “an expression of sorrow, regret or sympathy by a person that does not contain an acknowledgement of fault by that person”.

When signalling the need for open disclosure, or during the formal open disclosure discussions it is important that you do not:

  • speculate
  • attribute blame to yourself or others
  • criticise individuals
  • imply legal liability (for example using the word “negligent”).

All known facts relevant to the adverse event can be made available to the patient/family subject to any legal restrictions that may apply.

What can I tell the patient about the investigation into the clinical incident?

Any clinical incident must be appropriately investigated. A hospital/health service must decide whether to conduct an investigation with or without legal or qualified privilege.

Each of these pathways restricts what information can be disclosed to the patient and/or their nominated relatives/carers.

If a hospital/health service elects to undertake an investigation of a clinical incident using state qualified privilege, then no information pertaining to the investigation should be released to the patient until legal advice has been obtained.

Providing feedback to the patient and/or their nominated relatives/carers

Throughout the open disclosure process, where legally possible, the hospital/health service should provide regular feedback to the patient and/or their nominated relatives/carers.

The amount of information that hospital/health service staff can provide to the patient and/or their nominated relatives/carers about the outcomes of an investigation, recommendations or actions taken by the hospital/health service is dependent on the pathway under which an investigation was conducted.

At the end of the open disclosure process it is recommended that a final report is provided to the patient and/or their nominated relatives/carers.

The final report must take into account any prohibitions on the disclosure of information and must be cleared by the legal representative of the hospital/health service in consultation with RiskCover (external site).

How should I approach any ongoing care the patient may require?

When a patient requires further therapeutic management or rehabilitation, they should be involved in the development of their ongoing clinical management plan.

Where a patient requires ongoing medical treatment and support, which cannot be provided by the hospital, appropriate arrangements and advice should be given to the patient and their nominated relatives/carers on how to gain access to these services (for example, counselling).

Who can I talk to about implementing open disclosure processes?

When implementing the open disclosure process at the local level, all WA public hospitals/health services need to consult with:

This ensures that the operation of open disclosure does not breach any legislation, insurance policy or self-insurance cover document and meets all legal and insurance requirements.

Resources

References

  1. Australian Commission on Safety and Quality in Health Care. Australian Open Disclosure Framework. 2013.

More information

Quality Improvement and Change Management Unit
Address: 189 Royal Street, East Perth
Phone: 9222 4080
Email: qicm@health.wa.gov.au

Produced by

Quality Improvement and Change Management Unit