Open disclosure of adverse events: exploring the implications of service and policy structures on practice

Reema Harrison,1 Merrilyn Walton,2 Jennifer Smith-Merry,3 Elizabeth Manias,4,5 Rick Iedema6 1Faculty of Medicine, School of Public Health and Community Medicine, UNSW, Sydney, NSW, Australia; 2School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; 3Centre for Disability Research and Policy, Faculty of Health Sciences, The University of Sydney, Sydney, NSW, Australia; 4School of Nursing and Midwifery, Faculty of Health, Centre for Quality and Patient Safety Research, Deakin University, Sydney, NSW, Australia; 5Department of Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia; 6Centre for Team-Based Practice and Learning in Health Care, King’s College London, London, UK Purpose: The aim of this study was to explore the service and policy structures that impact open disclosure (OD) practices in New South Wales (NSW), Australia. Participants and methods: An explorative study using semi-structured interviews was undertaken with 12 individuals closely involved in the implementation of OD in hospitals at policy or practice levels within the state of NSW, Australia. Interviews explored the service and policy structures surrounding OD and the perceived impact of these on the implementation of the OD policy. These data were thematically analyzed to understand the factors facilitating and creating barriers to openness after adverse events. Results: The data identified three key areas in which greater alignment between OD policy and the wider service and policy structures may enhance the implementation of OD practice: 1) alignment between OD and root cause analysis processes, 2) holistic training that links to other relevant processes such as communicating bad news, risk management, and professional regulation and insurance, and 3) policy clarification regarding the disclosure of incidents that result in no or low-level harm. Conclusion: Evidence from this study indicates that formal OD processes are not routinely applied after adverse events in NSW, despite clear guidelines for OD. The reasons for this are unclear as the service-level and policy-level phenomena that support or hinder OD are understudied. This knowledge is critical to addressing the policy-practice gap. Our paper provides insights regarding the influence of current service-level and policy-level phenomena on the delivery of OD and how policy clarification may contribute to addressing some of the challenges for implementing OD policy. The principles of virtue ethics – specifically, openness and the involvement of service users – may contribute to progressing in this area. Keywords: incident disclosure, adverse events, health policy, hospitals, patient-centered care, qualitative researc