Checklist: Disclosing harm from healthcare delivery

• Seek to improve the patient’s existing clinical condition.
• Make the immediate clinical environment safe (e.g. remove malfunctioning equipment).
• Obtain informed consent for further clinical investigations, treatments, or consultations the patient needs.
• Consider whether it would be best for another physician to assume care of the patient.

Plan the initial disclosure

• Schedule the initial disclosure with the patient as soon as reasonably possible.
• Gather the facts to gain a preliminary understanding of what happened.
• Speak to other healthcare providers who were involved in the patient safety incident.
• Confirm whether there will be a quality improvement review of the patient safety incident.
• Organize the main discussion points.
• Anticipate and prepare for emotional reactions and questions from the patient and family.

Invite participants to attend the initial disclosure meeting

• Invite those individuals who have a direct role in providing clinical care and emotional support to the patient. Consider the patient’s wishes.

Conduct the initial disclosure

The most responsible physician, or an appropriate delegate, usually leads the initial disclosure meeting.

• Sit at eye level in a private area with the patient, free from interruptions.
• Begin the discussion with an expression of sympathy and compassion for the circumstances. Address the patient’s information and emotional needs.
• Explain what happened, focusing on the facts. Avoid jargon.
• Invite the patient to provide his or her perspective on what has happened.
• Avoid speculating or laying blame.
• Remain professional and take care not to appear defensive.
• Briefly outline the investigative process that will be followed and what the patient and family can expect to learn. If known, share specific timelines.
• Assess the patient’s level of understanding and satisfaction and ask if there is anything further that can be done to assist the patient at this time.
• Provide the patient with the name and telephone number of a person whom they can contact. This person may also periodically touch base with the patient, even when there is nothing new to report.

Quality improvement review

Physicians should contribute to properly structured and conducted quality improvement reviews.

Conduct the post-analysis disclosure

In hospital settings, hospital leaders usually lead the post-analysis disclosure meeting, while the responsible physicians may have a more limited role.

• Explain the conclusive, factual reasons for harm to the patient as determined by the quality improvement review. The focus should be on key learnings and improvements being made that could benefit other patients.
• Apologize to the patient, as appropriate. The nature of an apology for a poor clinical outcome will depend on the reason for the outcome. It is always appropriate to say you are sorry for the circumstances or condition of the patient.
• Avoid statements that express or imply legal responsibility, such as negligence or fault. Legal responsibility is not usually clear, and courts and medical regulatory authorities (Colleges) make these determinations.

Documentation

• Document all relevant details of disclosure meetings in the patient’s medical record, including meeting dates, matters discussed, and expressions of empathy.
• Document the patient’s clinical condition, including any informed consent discussions.