Adverse events and open disclosure

When healthcare harms someone, the practitioner is open and honest with the patient, reviews what happened and reports appropriately. Good practice means the practitioner: (a) documents the adverse event or incident; (b) recognises what happened and reports it to the proper authority where that is called for; (c) acts at once to fix the problem where possible, getting help and advice where needed; (d) applies open disclosure principles and non-punitive incident management; (e) explains to the patient and relevant people, as promptly and fully as possible and in line with open disclosure policies, what went wrong, how, what it may mean for them and the steps taken so it does not happen again; (f) listens, acknowledges distress and gives appropriate support, including referral; (g) complies with policies, procedures, reporting requirements and legislation (some jurisdictions have duty of candour laws) and asks an employer or professional indemnity insurer for advice if unsure; (h) reviews adverse events and makes changes to reduce recurrence (section 7); and (i) makes sure patients know how to complain, notify or raise a concern, for example through the Health Complaints Commissioner or the Board and Ahpra.

• Incident register entries for each adverse event with date, description and report destination
• Open disclosure record: date the patient was told, who was present, what was explained and the follow-up agreed
• Incident review or root cause analysis with the changes implemented
• Patient-facing information on complaint and notification routes

• Adverse events fixed quietly with no record or disclosure
• Disclosure given verbally with nothing documented
• Reviews completed but recommended changes never made
• Duty of candour obligations in the state not known to the practitioner