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Guidance on open disclosure policies (PDF,
HDC wishes to promote a clear and consistent approach to open
disclosure by health care and disability services providers. It is
what consumers want and are entitled to. Right 6 of the Code of
Health and Disability Services Consumers' Rights gives all
consumers the right to be fully informed (ie, to receive the
information that a reasonable consumer in his or her situation
would expect to receive). Consumers have a right to know what has
happened to them.
Internationally, there is a move towards the development of
national standards and organisational policies to promote open
disclosure. In New Zealand, provider organisations have a legal
duty to take steps to ensure that open disclosure is practised by
staff and supported by management.
Set out below are guiding points that provider organisations
should consider when developing open disclosure policies:
WHAT SHOULD OPEN DISCLOSURE INCLUDE?
- A consumer should be informed about any adverse event, ie, when
the consumer has suffered any unintended harm while receiving
health care or disability services.
- An error that affected the consumer's care but does not appear
to have caused harm may also need to be disclosed to the consumer.
Notification of an error may be relevant to future care decisions -
whether or not to go ahead with the same procedure on another
occasion. The effects of an error may not be immediately
- A disclosure should include acknowledgement of the incident, an
explanation of what happened, how it happened, why it happened and,
where appropriate, what actions have been taken to prevent it
happening again. (In some situations specific actions will need to
be taken straight away, whereas in other situations where the
explanation is still unfolding, the actions that need to be taken
may take longer to identify.)
- A disclosure should include a sincere apology. This is the provider's opportunity to say,
"We are sorry this happened to you." It is not about allocating
blame for the event's occurrence, but acknowledging the seriousness
of an adverse event and the distress that it causes. Apologies can
bring considerable comfort to the consumer and have the potential
to assist with healing and resolution. In
some situations, an apology may be critical to the consumer's
decision about whether to lay a formal complaint and pursue the
- The consumer should be given contact details and information
about the local health and disability consumer advocate as well as
options for making a complaint.
WHY IS OPEN DISCLOSURE IMPORTANT?
- Because ethically and legally it is the right thing to do.
- There are a number of rights under the Code of Health and
Disability Services Consumers' Rights (the Code) that are relevant
to open disclosure (see below).
- Open disclosure standards are included in the revised Health
and Disability Services Standards that must be followed by all
health and disability services providers certified under the Health
and Disability Services (Safety) Act 2001.
- Open disclosure:
o affirms consumers' rights;
o fosters open and honest professional
o enables systems to change to improve service
quality and consumer safety.
- Because the physical harm from an adverse event is often
compounded by an emotional or psychological harm when consumers
discover that relevant information has been withheld from them.
- Consumers want to know when things go wrong and why,
and providers and provider organisations
have a legal duty to promote the disclosure of such information in
accordance with their individual or organisational duty of
- Consumers want to know what the consequences could be for them
and their ongoing care. It is important to discuss how the event
could change anticipated care and any effects the consumer may
experience as a result.
- Consumers are also interested in any action taken as a result
of the error or adverse event. Many are concerned that the same
thing does not happen to anyone else, that changes are made to the
relevant systems, and that staff learn from the experience.
- It also helps ensure consumers are advised that they may be
entitled to compensation under ACC, so appropriate forms can be
completed in a timely manner.
WHO SHOULD BE INVOLVED IN THE DISCLOSURE?
- The individual provider with overall responsibility for the
consumer's care should usually disclose the incident. Research
suggests that consumers prefer to hear from a provider with whom
they have built a rapport or had previous contact. Where this
provider is not the provider with overall responsibility, both
providers should be in attendance.
- Research suggests that disclosures by administrative staff or
management alone are not well received, although in some cases,
particularly where significant harm has resulted, it may be
appropriate for senior management to attend with the individual
WHEN/WHERE SHOULD THE DISCLOSURE TAKE
- Disclosure should be made in a timely manner, usually within 24
hours of the event occurring, or of the harm or error being
- Although disclosure to the consumer concerned should not occur
until he or she is medically stable enough to absorb the
information and is in an appropriate setting, there is likely to be
a suitable person (ie, someone who is interested in the welfare of
the consumer and is available) who should be informed. This may
include an enduring power of attorney or legal guardian.
- In the immediate aftermath of an adverse event, providers may
be searching for answers too. In these circumstances it is
appropriate to acknowledge the limits of what is known, and to make
a commitment to sharing further information as it becomes
- It is important to emphasise that open disclosure is not a
single conversation, but a process of ongoing communication.
Communication should continue until the consumer (and/or the
consumer's representative or the suitable person who has been
informed) has all the information and support needed.
- If the incident occurred in a team environment, it may be
beneficial for the team to meet prior to the disclosure taking
place. The Medical Council of New Zealand's guidelines for doctors
suggest that the team meet to discuss:
o what happened
o how it happened
o the consequences for the consumer, including
arrangements for continuity of care
o what will be done to avoid similar
occurrences in the future
o who should be present when the harm is
disclosed to the consumer.
- It might not be possible, however, for the team to discuss the
incident and any harm before a discussion with the consumer takes
place. An opportunity for the team to debrief should not
unreasonably delay the consumer's (or his or her representative's)
receipt of information.
- It may be appropriate for an early initial disclosure to occur,
followed by a more detailed discussion with the consumer once the
team has had an opportunity to meet.
HOW SHOULD OPEN DISCLOSURE TAKE PLACE?
- Disclosures should generally be made to the individual consumer
and any family/whanau/key support people the consumer wishes to
- In some situations where the consumer has died, has been
significantly compromised, has long-term diminished competence, or
is incompetent, disclosure will need to be made to a third
- In circumstances where discussion with the consumer is not
possible or appropriate, his or her representative, or a suitable
person (who is interested in the welfare of the consumer and is
available), such as the consumer's next of kin or designated
contact person, should be informed.
- Consideration must be given to the consumer's cultural and
ethnic identity and first language, and the support needed.
- Details about the incident and any harm, the disclosure, and
any subsequent action should be fully documented in the consumer's
- It is important that health professionals and other personnel
involved also have access to support. Numerous studies have shown
that most errors are made by well-trained people who are trying to
do their job, but are caught in a flawed system that predisposes
towards mistakes being made.
- Provider organisations need to take steps to ensure that the
policy is applied in practice. Ongoing staff training on open
disclosure needs to take place so that staff are able to respond
promptly and confidently when things go wrong. All personnel,
including providers with independent access agreements and relevant
contractors such as relief providers, also need to be aware of the
policy, and adequately trained and supported in its
- Training in communication is especially important. An adverse event or incident is emotionally
charged for all parties, and specific skills are required to
deliver bad news in a sincere, compassionate and thoughtful way.
Effective communication and empathy is pivotal to the open
RELEVANT RIGHTS UNDER THE CODE
- Right 1 provides that consumers have the right to be treated
with respect. Respect requires a truthful and sensitive discussion
about any harm or incident affecting the consumer.
- Under Right 4(1) providers have an obligation to provide
services with reasonable care and skill. Provider organisations
have an organisational duty of care which includes the need to have
a policy on open disclosure that is well understood and implemented
by all personnel.
- The provision of information in a form, language, and manner
that enables the consumer to understand the information provided is
required by Right 5(1). Right 5(2) also applies as it requires an
environment supporting open, honest and effective
- Right 6(1) affirms the right to the information that a
reasonable consumer, in that consumer's circumstances, would expect
to receive. It is seldom reasonable to withhold information about a
consumer from that consumer.
- Health and disability services providers have a duty of open
disclosure under Right 6(1)(e) according to legal, professional,
ethical, and other relevant standards.
- Right 6(3) gives consumers the right to honest and accurate
answers to questions relating to services, including information
about the identity and qualifications of providers and how to
obtain an opinion from another provider.
- Right 6(4) gives consumers the right to receive, on request, a
written summary of information provided.
- Right 8 - the right to have a support person(s) present - is
particularly relevant in distressing situations and when people
receive bad news or a shock.
Right 10 also requires providers to ensure that consumers are
made aware of their right to complain and provided with information
about the complaint process and their options.
 See R Lamb, "Open disclosure: the
only approach to medical error" (2004) 14 Quality and Safety in
Health Care 3.
 Ministry of Health, New Zealand
Standard Health and Disability Services Standards, NZS
 See C Vincent and A Coulter,
"Patient safety: what about the patient?" (2002) Quality and
Safety in Healthcare 11(1): 76-80.
 M Bismark, E Dauer, R Paterson and D
Studdert, "Accountability sought by patients following adverse
events from medical care: the New Zealand experience" (2006) 175
CMAJ 889; M Bismark and R Paterson, "'Doing the right
thing' after an adverse event" (2005) 1219 NZMJ 55;
A Witman, D Park and S Hardin, "How do patients
want physicians to handle mistakes? A survey of internal medicine
patients in an academic setting" (1996) 156 Archives of
Internal Medicine 2565; M Higorai, T Wong and G Vafidis,
"Patients' and doctors' attitudes to amount of information given
after unintended injury during treatment: cross-sectional,
questionnaire survey" (1994) 318 BMJ 640.
 New Zealand Medical Council,
Disclosure of harm 'Good Medical Practice', December 2004
(available at www.mcnz.org.nz).
 M Bismark and R Paterson, "'Doing
the right thing' after an adverse event" (2005) 1219 NZMJ
 New Zealand Medical Council,
Disclosure of harm 'Good Medical Practice', August 2008
(available at www.mcnz.org.nz).
 L Leape, "Preventing Medical
Accidents: Is 'systems analysis' the answer?" (2001) 27
American Journal of Law and Medicine 145.
 See Massachusetts Coalition for the
Prevention of Medical Errors, When things go wrong: responding
to adverse events (2006) 19.
 See Australian Council for Safety
and Quality in Healthcare, Open disclosure: health care
professionals handbook (2003) 13.