An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration

Abstract

BackgroundIn 2009 the UK National Patient Safety Agency relaunched its Being Open framework to facilitate the open disclosure of adverse events to patients in the NHS. The implementation of the framework has been, and remains, challenging in practice.AimThe aim of this work was to both critically evaluate and extend the current evidence base relating to open disclosure, with a view to supporting the implementation of a policy of open disclosure of adverse events in the NHS.MethodsThis work was conducted in three phases. The first phase comprised two focused systematic literature reviews, one summarising empirical research on the effectiveness of interventions to enhance open disclosure, and a second, broader scoping review, looking at reports of current opinion and practice and wider knowledge. The second phase involved primary qualitative research with the objective of generating new knowledge about UK-based stakeholders’ views on their role in and experiences of open disclosure. Stakeholder interviews were analysed using the framework approach. The third phase synthesised the findings from the first two phases to inform and develop a set of short pragmatic suggestions for NHS trust management, to facilitate the implementation and evaluation of open disclosure.ResultsA total of 610 papers met the inclusion criteria for the broad review. A large body of literature discussed open disclosure from a number of related, but sometimes conflicted, perspectives. Evidential gaps persist and current practice is based largely on expert consensus rather than evidence. There appears to be a tension between the existing pragmatic guidance and the more in-depth critiques of what being consistent and transparent in health care really means. Eleven papers met the inclusion criteria for the more focused review. There was little evidence for the effectiveness of disclosure alone on organisational or individual outcomes or of interventions to promote and support open disclosure. Interviews with stakeholders identified strong support for the basic principle of being honest with patients or relatives when someone was seriously harmed by health care. In practice however, the issues are complex and there is confusion about a number of issues relating to disclosure policies in the UK. The interviews generated insights into the difficulties perceived within health care at individual and institutional levels, in relation to fully implementing the Being Open guidance.ConclusionsThere are several clear strategies that the NHS could learn from to implement and sustain a policy of openness. Literature reviews and stakeholder accounts both identified the potential benefits of a culture that was generally more open (not just retrospectively open about serious harm). Future work could usefully evaluate the impact of disclosure on legal challenges within the NHS, best practice in models of support and training for open disclosure, embedding disclosure conversations in critical incident analysis and disclosure of less serious events.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Being open about unanticipated problems in health care: the challenges of uncertainties

“…Some also described a range of painful experiences that had followed unanticipated adverse outcomes. 7 However, these concerns and experiences did not seem to be the only, or even the main, drivers of their intentions and practice relating to open disclosure. As has been observed when examining other aspects of professional safety behaviour, factors beyond blamerelated fear appeared significant.…”

“…We draw on our recent research into the implementation of the Being open policy and framework in England and Wales, making use of insights from interviews with health care professionals, including clinical managers. 7 We extend our original analysis to highlight some of the complexities of considerations that health care professionals bring to bear as they contemplate the discussion of a diverse range of problems and some of the limitations of current guidance about open disclosure in these situations. Our methods have been reported elsewhere 7 The Being open framework is underpinned by 10 principles (Box 2) designed to reinforce and Box 1.…”

“…7 We extend our original analysis to highlight some of the complexities of considerations that health care professionals bring to bear as they contemplate the discussion of a diverse range of problems and some of the limitations of current guidance about open disclosure in these situations. Our methods have been reported elsewhere 7 The Being open framework is underpinned by 10 principles (Box 2) designed to reinforce and Box 1. Summary of methods and data sources.…”

“…Summary of methods and data sources. 7 1. Literature reviews were conducted to summarize empirical research on the effectiveness of interventions to enhance open disclosure and to describe and synthesize reports of current opinion and practice and wider knowledge.…”

“…There appears to be international consensus that when things go wrong, discussions should include: an acknowledgement, an expression of regret and/or an apology where an error has occurred and an explanation of what happened; reassurance for patients, their families and carers that the problem has been or is being investigated and lessons will be learned to help prevent the problem recurring; and support for those involved to cope with any physical and psychological consequences of what happened. 7 Strong arguments that open disclosure is the right thing to do when things go wrong in health care have been made with reference both to the duties, obligations and aspired to virtues of health care providers and to the associated rights and needs of patients and relatives. 8,9 valuable for reinforcing cultures of openness in health care organizations and encouraging reporting for learning from unanticipated events in health care safety.…”