One system's journey in creating a disclosure and apology program

Area of Science:

• Healthcare quality improvement
• Patient safety initiatives
• Medical ethics

Background:

• Adverse events in healthcare occur more frequently than perceived.
• A growing number of health systems advocate for open and compassionate disclosure of adverse events.

Purpose of the Study:

• To describe the implementation of an enhanced program for prompt and skillful disclosure of adverse events.
• To outline the model for a disclosure and apology program at Baystate Health.
• To detail the expansion of emotional support services for patients, families, and clinicians.

Main Methods:

• Formation of a disclosure advisory committee in 2006.
• Development of a program model similar to a hospital ethics consultation service.
• Hiring of external trainers for coaches/facilitators and formalization of emotional support.

Main Results:

• The program increased internal pressure for prompt causality determination of adverse events.
• Enhanced response to patient and family requests for information and assistance.
• Challenges identified in promptly investigating events and determining root causes and system culpability.

Conclusions:

• Patients expect systemic changes after medical errors to prevent future harm.
• Healthcare systems must implement robust systems to reduce future risks and ensure patient suffering is not in vain.
• Sustaining such programs requires effective investigation, accurate liability determination, empathetic communication, and a just culture.