Health professionals' perceptions and experiences of open disclosure: a systematic review of qualitative evidence.

Review question/objective The objective of this systematic review is to synthesise the best available qualitative evidence available exploring health professionals' perceptions and experiences of open disclosure of medical errors to patients. Consequently the question to be addressed is: What are the perceptions and experiences of health professionals regarding open disclosure of medical errors to patients? More specifically to explore where possible: What are the perceptions and experiences of barriers to open disclosure of medical errors to patients by health professionals? What are the perceptions and experiences of facilitators of open disclosure of medical errors to patients by health professionals? Background In 1999 the Institute of Medicine (IOM) released its ground breaking report ‘To Err is Human: Building a Safer Health System’, drawing worldwide attention to the issue of patient safety in healthcare.1 The IOM reported that up to 98,000 people die in hospitals across the United States of America each year as a result of medical error, with an estimated additional cost of $17 billion to $29 billion at that time, to the annual health care budget. ‘To Err is Human’ report exposed not only the human cost with increasing mortality rates but went further to identify these types of errors as a chronic threat to public health.1–3 The ethical imperative “first do no harm” has been a fundamental principle for the medical profession since Hippocratic times.3–5 However, health care by its very nature is intrinsically risk laden and potentially hazardous for patients. Despite the best intentions of health professionals and organisations mistakes are universal to the human experience and can occur at all levels of personal and professional life.6, 7 A medical error is considered to be a preventable adverse event where a patient has been harmed as a consequence of either what has been done to them, an error of commission, or what has not been done, an error of omission.8, 9 Providing patients with information after any unanticipated outcome of their care is an established ethical expectation for all health professionals.10 The Ethics Manual of the American College of Doctors states that rules for truth telling precedes the principle of respect for patient autonomy.5, 9–11 Historically, healthcare decisions surrounding the appropriateness, timing and content of medical information provided to patients has remained a private matter, which has been left to the preferences and discretion of individual clinicians and health care institutions.12–14 The literature suggests the development of a systematic framework for health professionals to respond to medical errors and provide information to patients supports the notion of quality health care.7, 14 A structured process promotes a collaborative and cohesive approach to the management of errors and guides health professionals on what immediate steps to take when an error occurs and provides strategies to support their interactions with the involved patient and their family.15,16 Open disclosure is defined as providing an open, consistent approach to communicating with patients following an adverse event.10, 14, 17, 18 It has been suggested the practice of open disclosure plays a pivotal role in patient safety.19, 20 Its implementation and compliance in practice facilitates the flow of critical information, provides the organisation with vital opportunities to examine medical errors, the circumstances in which they occurred, and translate the lessons learnt from medical errors into concrete changes to improve practices and thereby reducing the risk of harm to others.18–22 The Joint Commission on Accreditation of Healthcare (JCAHO) has endorsed its effectiveness as a patient safety strategy with the introduction of a new standard in 2001 requiring hospitals to inform patients of all unanticipated outcomes of care that they experienced.23 Internationally, there is a move towards open disclosure and several countries have mandated polices in direct response to increasing rates of litigation claims associated with medical errors.14, 23, 24 Investigations into this area of litigation suggests the motivation for patients to file lawsuits is not simply because they believe there has been negligence, but because of a breakdown in communication with their providers. Patients who believe they are not being told everything surrounding the error will often take legal action simply to learn the details of what actually happened.10, 18, 24 – 27 Patient centred models of care are recognised as essential to effective, quality health care delivery.28 The fundamental principles of patient centred care are ensuring clinical decisions are respectful of and responsive to the individual patients' preferences, needs and values.10, 29, 32 To identify the needs of patients, studies examining the expectations of patients and their families on what happens after an event have been investigated across health domains. The findings suggest that patients both expect and desire open disclosure of medical errors; they want an explanation of what happened. Patients also want to be assured the organisation has learnt from these errors and actively moves forward with implementing measures to prevent similar errors from happening to others in the future.16, 19, 33–36 The ethical duty to error disclose has been widely acknowledged, however there is evidence to suggest such disclosure is inconsistent in practice and it continues to be a controversial issue amongst some health professionals.7, 11 Studies suggest that there is a significant gap between the level of endorsement by health professionals in theory and the level of disclosure experienced by patients in reality.3, 23, 37 Studies examining the behaviours of physicians suggest there are a variety of factors that impinge upon their readiness to disclose errors to patients. These include the fear of litigation, a strong cultural reluctance within medicine to admit mistakes and a fear they would lose the support of their colleagues or the organisation in which they practice.7 Physicians also fear that by informing patients about a mistake they would risk losing their professional and personal reputation.7, 30 Physicians also held the perception and belief that patients would not want to know if an error had occurred and if they were to inform patients about an error the patient was not likely to understand what they were being told. Furthermore, physicians were less likely to disclose an error if they believed the patient was unaware an error had actually taken place. 31,32, 38 The literature suggests other health professionals beyond physicians fail to disclose errors for several reasons including, a desire to protect patients and their family from any additional anxiety and distress, to prevent undermining the patients trust in the care that they are receiving and to protect their relationship with the patient and their family.7, 28–31, 39 Open disclosure is a complex and challenging process, it requires courage, composure, communication skills and a fundamental belief that the patient is entitled to know the truth.22 It pushes the traditional practice of sharing medical-clinical knowledge with patients to new limits and such conversations require specific skills as they are likely to raise issues of failure, harm, loss of trust and have the potential to generate intense emotions of anxiety, anger, depression and guilt.38, 40 The literature suggests one of the key facilitators promoting the practice of open disclosure is an environment where health professionals are provided with the moral and emotional support they need when medical errors occur. Similarly, establishing a professional environment where errors can be openly discussed and examined without fear.41 The way medical errors are managed in practice can have a significant long term effect on the perceptions, confidence, self esteem and long term attitudes especially of novice nurses, medical students and junior doctors who are considered to be most vulnerable during their early stages of professional development.39 A system-wide approach underpinned by evidence of the factors instrumental to both help and hinder open disclosure is recommended to manage the complexities of this important issue and to minimise the negative impact on health professionals, patients and their families.20, 34 Providing safe, patient focused care is a major challenge confronting today's increasingly complex health care system. Open disclosure represents a new dimension of accountability and challenges the traditional hierarchical values and practices of health professionals. The literature suggests open disclosure has beneficial consequences for patient safety; it supports the patient's right to be informed when something goes awry during their care and promotes the virtues of honesty and humility amongst health professionals.2 This systematic review is important to gain collective insight into the contextual factors that help and also those that hinder open disclosure. Synthesis of the findings of the available research on this issue will assist in patient-practitioner communication and trust in clinical practice and benefit clinicians' in exposing principles that may not have previously been discussed openly. The evidence will inform healthcare policy makers and support a system wide approach in the development and implementation of open disclosure policy. Prior to the commencement of this systematic review, the Joanna Briggs Institute (JBI) Library of Systematic reviews, the Cochrane Database of Systematic reviews and CINAHL databases were searched and no previous systematic reviews on this specific topic were identified. Inclusion criteria Types of participants This review will consider studies that include health professionals that are qualified/registered. This review will exclude studies that include student health professionals. Phenomena of interest This review will consider studies that investigate health professionals' perceptions and experiences regarding open disclosure of medical errors to patients. This review will consider studies that are set in primary, secondary and tertiary settings. This review will exclude the following: Study setting involving alternative and complementary therapy. Types of studies This review will consider studies that focus on qualitative data including, but not limited to, designs informed by phenomenology, grounded theory, ethnography and action research. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in this review. An initial limited search of pubmed and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in the English language will be considered for inclusion in this review. Studies published from 1995 until present will be considered for inclusion in this review to gather contemporary information brought to the fore with the release of the 1999 Institute of Medicine report ‘To Err is Human: Building a Safer Health System’.1 The databases to be searched include: CINAHL PubMed Embase PsycINFO Organisation web pages to be searched will include Agency for Healthcare Research and Quality (AHRQ) Australian Institute for Health and Welfare (AIHW) Australian Commission on Safety and Quality Health Institute for Health Care Improvement (IHI) World Health Organisation (WHO) Joint Commission on Accreditation of Healthcare Organisation (JCAHO) Joint Commission International Accreditation (JCIA) The search for unpublished studies will include: MedNar WorldWideScience.org ProQuest Dissertations & Theses Database (PQDT) Dissertation Abstracts Online (DIALOG) Initial keywords to be used will be: Full disclosure Open disclosure Medical errors Medical mistake*[tiab] Surgical error*[tiab] Diagnostic error* [tiab] Iatrogenic diseases[mh] Iatrogenic[tiab] Attitude of health personnel[mh:noexp] Physician-patient relations[mh] Physician patient [tiab] Doctor patient [tiab] Professional-patient relations [mh:noexp] Nurse-patient relation[mh] Nurse patient[tiab] Nurse's role[mh] Nurse's role[tiab] Nurses role[tiab] Truth disclosure[mh:noexp] Disclosure[tiab] Truth[tiab] Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes relevant to the review question and specific objectives. Data synthesis Qualitative research findings will, where possible be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Conflicts of interest No potential conflict of interest is anticipated. Acknowledgements As this review forms partial submission for a Master of Clinical Science, a secondary reviewer will be involved in critical appraisal only.