1219 / A National Approach to the Disclosure of Adverse Events with Patients

Type of Patient Safety Practice
Clinical Practice (CP)
“Best fit” category of the reported practice
Topic of the reported practice
Patient involvement
Aim and the benefit of the Patient Safety Practice
The healthcare provider relationship is built on a foundation of trust, honesty and openness.Research has demonstrated that if patients are not communicated with following an adverse event they are more likely to pursue a complaints/ litigious route. These processes can be negative, time consuming and costly. Communicating effectively is therefore a vital part of the incident management process. It promotes person centred care and a just culture which encourages learning from adverse events and continuous improvement in the delivery of health and social care services. An adverse event is an incident which results in harm to a person that may or may not be the result of an error.
Description of the Patient Safety Practice
In January 2007, Mary Harney, Minister for Heath & Children established the Commission on Patient Safety and Quality Assurance (“the Commission”) and instructed it, among other tasks, to develop clear and practical recommendations which would ensure the safety of patients. In July 2008, the Commission completed its report entitled Building a Culture of Patient Safety. The report was published in August 2008 and approved by the Government in January 2009.
One of the key recommendations of the report is the development and support of a culture of open disclosure to patients and their next-of-kin, following an adverse event resulting in harm to a patient. Open Disclosure is defined by the Australian Commission on Safety and Quality in Health Care as “an open, consistent approach to communicating with patients when things go wrong in healthcare. This includes expressing regret for what has happened, keeping the patient informed, providing feedback on investigations and the steps taken to prevent a recurrence of the adverse event.”In October 2010 the HSE and State Claims Agency commenced a national pilot project in relation to Open Disclosure. A project lead was identified from both agencies. Ms. Ann Duffy, Clinical Risk Advisor is the national lead in open disclosure for the State Claims Agency and Ms Angela Tysall, Project Manager, National Advocacy Unit is the national lead for the HSE. A national project team was established. Two pilot sites were identified as follows: The Mater Misercordiaie University Hospital, Dublin and Cork University Hospital, Cork City. The project objective is to provide training and support for doctors and other healthcare professionals to support them in engaging in the open disclosure process with a view to the development of a national guidance document and national policy on Open Disclosure.The Open Disclosure programme supports the recently introduced National Standards for Safer Better Healthcare 2012 which now have immediate effect under the Health Act 2007.

Project Proposal: A draft project proposal was drawn up by the national projects leads. The proposal outlined (a) the responsibilities of the pilot sites in relation to the implementation of open disclosure, (b) examples in relation to how compliance with these responsibilities may be demonstrated and (c) the supports which were available to them by the SCA, HSE and National Project team. The aim of the proposal was to assist the pilot sites to take a structured change management approach towards implementing Open Disclosure within their organisations in line with international best practice and in keeping with the principles of open disclosure.
The National Project Leads have emphasised the importance of staff support and the debriefing of staff who have been involved in an adverse event. This is also incorporated as part of the staff awareness sessions delivered to all staff groups in the pilot sites by the national project leads and staff support is also covered in detail in the half day Open Disclosure workshops. Awareness sessions are approx 30 minutes long and provide an informed overview of open disclosure and the pilot responsibilities. These sessions were open to all staff, with all sessions evaluated.

Training: The national project leads developed a half day workshop programme to be delivered to all staff identified by the pilot sites as lead disclosers or who would be assisting staff and patients/their families during the disclosure process. The workshops are CPD accredited with the RCSI, RCPI and ABA. The national project leads developed a practical workbook and reference folder based on the ROI healthcare system, using predominately ROI health care system case studies. The reference material is evidence based and incorporates the learning from countries who have previously introduced disclosure programmes. A workshop evaluation tool was also developed to assess each workshop.
The OD project is more than a pilot, it is also a change management project that requires a significant cultural shift.

The programme has recently been evaluated by an external evaluator, the results of which are currently being reviewed.

Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
Effectiveness of the Patient Safety Practice
Degree of implementation of reported practice
Yes, partly
Level of implementation of reported practice
Regional or national level
Specific and measurable outcome for the reported practice were defined
A baseline measurement before implementation of the reported practice was obtained
A measurement after full implementation of the reported practice was obtained
Evaluation of a “positive” effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation’s results
Results not yet published, evaluation in draft for review.
Health care context where the Patient Safety Practices was implemented
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Specification of implementation in another health care setting(s)
Primary care
Successful implementation’s level  of this Patient Safety Practice across settings
Yes, across multiple specialities across different health care settings
Involved health care staff
Social workers
Quality manager
Risk manager
Patient Involvement
Direct service user’s involvement as integral part of this Patient Safety Practice
Specification of the service users or their representatives’ involvement in the implementation of this Patient Safety Practice
Patient organisation(s)
Point of time in which service user or their reprasentatives’ involvement takes place
During the implementation of the Patient Safety Practices
During the application of the Patient Safety Practice
Active seeking of service users’ opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Short description of the service users’ level of involvement
Collaboration, such as co-designing a Patient Safety Practice or active partnership in implementation
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
List of sources where public information is accessible
National guidelines publication
Patient leaflets
Implementation of the Patient Safety Practice
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
Lack of knowledge on implementation strategies
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Description of used incentives, if any.
The project leads supported the implementation of open disclosure in a number of ways:
1.The introduction of a business plan to help inform the process and suggest practical means of implementation with designated personnel.
2.An evidence based approach was used, taking into account a number of countries including the Australian model.
3.National policy and practical guidance were published, with an FAQ section detailing commonly asked questions.
4.A training plan and training day accredited by professional bodies for doctors, nurses and allied healthcare was rolled out nationally.
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Costs of the Patient Safety Practices
Completion of cost calculation related to this Patient Safety Practice
Total number of person days required to implement this Patient Safety Practice
Clinical staff:
External consultants:
Support staff:
Managerial staff:
Not relevant:
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff:
External consultants:
Support staff:
Managerial staff:
Not relevant:
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here