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Telephone:
416 928-0900
Toll Free in Ontario:
1 800 387-5526
Fax:
416 928-6507
Last modified August 26, 2004
What's New
Best Practices in Disclosing Health Care Error
Originally featured in Quality Practice.
How a facility deals with a health care error can either exacerbate an already painful incident or, through disclosure, promote openness, healing, learning and prevention. According to research by the Institute for Safe Medication Practice (ISMP) Canada, Healthcare Papers and The Royal College of Physicians and Surgeons of Canada, open disclosure is the most effective way to deal with an error. Below are some tips that employers can use to help staff manage these situations.
- Be Prepared: Have open disclosure policies and procedures.
Provide staff with education and training — such as simulation
exercises — on how to handle disclosure. Consider having staff
members who have had experience disclosing errors mentor others.
- Have a key contact person or team: Key individuals or teams
need to be ready and available to help staff deal with adverse events.
Planning how to deal with an occurrence and clearly outlining the roles
and accountability increases the likelihood that an adverse event will
be handled professionally. It also ensures that the focus will be on
the needs of the client and her/his family.
- Disclose as soon as possible: The health care professionals
directly involved in the client's care should speak to the client as
soon as she/he is physically and emotionally stable. If the client is
deceased, disclose to the family as soon as possible.
- Choose an appropriate setting: The setting should be as private
and comfortable as possible to facilitate communication and to avoid
distractions.
- Acknowledge that a mistake has been made.
- Describe the course of events, using non-technical language.
- State the nature of the mistake, the consequences, and the corrective action taken.
- Express regret and apologize, if appropriate.
- Elicit questions or concerns and commit to addressing them.
- Provide follow-up to the client: Indicate what steps the health
care facility will undertake to follow up on the incident and let her/him
know when she/he can expect further information.
- Provide support and guidance to staff: It is emotionally devastating
for health care professionals to realize that their error has harmed
a client or caused a death. Health care professionals are sometimes
referred to as the "secondary victims" of error, and their
personal and professional suffering can be worsened by a lack of support.
- Learn what happened: Research has shown that most health care
errors are not the result of negligence, are not random, and result
from human and systems errors. Taking an open approach to identifying
the cause of error can help organizations design system improvements
to "make it easier do the right thing."
- Communicate the incident: Help prevent future errors. Contact other facilities that may be at risk for committing the same error. E.g. in a case of medication error using an experimental drug, contact other facilities participating in the clinical trial. Report medication errors to ISMP Canada's Medication Errors Reporting Program.
Resources for Employers
ISMP Canada has many resources available for health care professionals
at www.ismp-canada.org.
In 2002, the National Steering Committee on Patient Safety released Building a Safer System: A National Integrated Strategy for Improving Patient Care (see www.rcpsc.medical.org), which lead to a national study on the extent of adverse events in the Canadian health care system. The Canadian Adverse Events Study (see Reports & Research, http://secure.cihi.ca), run jointly by the Canadian Institute for Health Information (CIHI) and the Canadian Institutes of Health Research (CIHR), will be released in 2004. However, a number of recommendations for designing safer systems can be found in Making Patients Safer! Reducing Error in Canadian Healthcare. It is available at www.longwoods.com/hp/index.html.
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