Rick Iedema professor (organisational communication) AbstractObjectives To investigate patients' and family members' perceptions and experiences of disclosure of healthcare incidents and to derive principles of effective disclosure.Design Retrospective qualitative study based on 100 semi-structured, in depth interviews with patients and family members.Setting Nationwide multisite survey across Australia.Participants 39 patients and 80 family members who were involved in high severity healthcare incidents (leading to death, permanent disability, or long term harm) and incident disclosure. Recruitment was via national newspapers (43%), health services where the incidents occurred (28%), two internet marketing companies (27%), and consumer organisations (2%). Main outcome measures Participants' recurrent experiences and concerns expressed in interviews.Results Most patients and family members felt that the health service incident disclosure rarely met their needs and expectations. They expected better preparation for incident disclosure, more shared dialogue about what went wrong, more follow-up support, input into when the time was ripe for closure, and more information about subsequent improvement in process. This analysis provided the basis for the formulation of a set of principles of effective incident disclosure.Conclusions Despite growing prominence of open disclosure, discussion about healthcare incidents still falls short of patient and family member expectations. Healthcare organisations and providers should strengthen their efforts to meet patients' (and family members') needs and expectations. IntroductionHealth providers in Western countries are adopting "open disclosure" policies that promote the discussion of healthcare incidents with patients.1-5 Studies using hypothetical designs have suggested that a gap exists between clinicians' and patients' views of what is appropriate incident disclosure. Clinicians tend to consider unexpected clinical outcomes as less serious and therefore less in need of disclosure than do patients. 6 Clinicians also err on the side of caution, whereas patients expect openness and admission of responsibility.7 Such breakdowns in the disclosure process exacerbate the distress patients experience from the event itself. Several studies have highlighted clinicians' concerns about the personal, professional, and legal consequences of disclosure. 10Clinicians are also concerned about the considerable time and effort often required for incident disclosure, 11 including ; and the importance of provider responses that are caring, honest, quick, personal, accessible, and frequent. 15 Some studies suggest that patients may have an interest in extending disclosure discussions to encompass plans for and evidence of practice improvement, with some interviewees indicating interest in contributing to the monitoring of improvement processes over time. 9 14 16 However, few studies have measured the actual experiences of patients and families with the disclosure process. The dearth of i...

Nurses must understand the complex needs of people with dementia in hospital. Nurse education about dementia, practical support, strong clinical leadership and role-modelling is needed. Empathy for patients regardless of diagnosis must remain a core attribute of nurses. Current hospital culture requires wider system review to mitigate against stigmatisation of patients with dementia.

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SummaryWe re-analysed prospective data collected by anaesthetists in the Anaesthesia Sprint Audit of Practice (ASAP-1) to describe associations with linked outcome data. Mortality was 165/11,085 (1.5%) 5 days and 563/11,085 (5.1%) 30 days after surgery and was not associated with anaesthetic technique (general vs. spinal, with or without peripheral nerve blockade). The risk of death increased as blood pressure fell: the odds ratio (95% CI) for mortality within five days after surgery was 0.983 (0.973-0.994) for each 5 mmHg intra-operative increment in systolic blood pressure, p = 0.0016, and 0.980 (0.967-0.993) for each mmHg increment in mean pressure, p = 0.0039. The equivalent odds ratios (95% CI) for 30-day mortality were 0.968 (0.951-0.985), p = 0.0003 and 0.976 (0.964-0.988), p = 0.0001, respectively. The lowest systolic blood pressure after intrathecal local anaesthetic relative to before induction was weakly correlated with a higher volume of subarachnoid bupivacaine: r 2 À0.10 and À0.16 for hyperbaric and isobaric bupivacaine, respectively. A mean 20% relative fall in systolic blood pressure correlated with an administered volume of 1.44 ml hyperbaric bupivacaine. Future research should focus on refining standardised anaesthesia towards administering lower doses of spinal (and general) anaesthesia and maintaining normotension.