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

Abstract

Discussion of unanticipated problems in care with patients and their families ('open disclosure') is now widely advocated. Despite international efforts and the introduction of a range of policies and guidance to promote such discussions, the expectations of policy makers and patients are often not matched in practice. We consider some reasons for the persistence of shortfalls in the occurrence and quality of open disclosure. We draw on research conducted to investigate the implementation of a 'Being open' policy in England, reflecting particularly on insights derived from interviews with health care professionals. Health care professionals were broadly supportive of the idea of open disclosure. Some expressed wellrecognized concern about punishment and being blamed, but this did not appear to be the main driver of their communication practices. Their accounts of what happened around particular problems in health care indicated that they brought a complex range of considerations to bear on questions of whether and how these were discussed with patients and relatives. Guidance about open disclosure based on assessments of levels of harm to patients can complicate and perhaps distort health care professionals' approaches, particularly when the extent and/or cause of harm was uncertain. Health care professionals who engage in open disclosure must be able to negotiate appropriate ways through complex and sensitive discussions. The responses of patients and relatives are not always predictable and even the best open disclosure practice may not resolve problems and concerns. Guidance, training and support for staff need to reflect these challenges.

Patient participation in patient safety still missing: Patient safety experts' views

“…Our results are consistent with findings that 37% of patients surveyed in the collection of statistics for Eurobarometer 2014 who reported an adverse event said that their report elicited no response, and only 20% of affected patients received an apology from the doctor or nurse concerned. Although discussion of unanticipated problems in patient care is widely advocated, it rarely meets patients' expectations . Incident disclosure is often thwarted by professionals' fear of lawsuits, a culture of blame in the health services, clinicians' lack of confidence in their own communication skills and general doubts about the efficacy and effectiveness of incident disclosure .…”

“…Although discussion of unanticipated problems in patient care is widely advocated, it rarely meets patients' expectations. 32 Incident disclosure is often thwarted by professionals' fear of lawsuits, a culture of blame in the health services, clinicians' lack of confidence in their own communication skills and general doubts about the efficacy and effectiveness of incident disclosure. 33,34 To combat such failings, healthcare professionals need guidance, training and support.…”

Enacting open disclosure in the UK National Health Service: A qualitative exploration

“…Recent high profile cases, such as the events occurring at the Mid‐Staffordshire Hospital Trust in the UK demonstrate that the practice of open disclosure continues to fall short of patient and family expectations . Fears of litigation, a health service culture of secrecy, lack of confidence amongst health professionals, fear of exacerbating patient's distress, and doubts regarding the effectiveness of open disclosure in meeting patients' needs relating to adverse events (AEs) are identified in the literature as the main reasons for nondisclosure …”

Safety lessons: shifting paradigms and new directions for patient safety research

“…However, there were some important contributions, including a study by Birks and colleagues on 'open disclosure' to patients who have been harmed while receiving health care. 42 This is important, given that existing studies suggest that less than a third of harmful errors are discussed with patients at present. There is a small but growing amount of evidence on this topic, largely from Australia or the United States, much involving only small-scale training or pilot initiatives.…”