The National Quality Forum's "Safe Practice Disclosure" recommends that "following serious unanticipated outcomes, including those that are clearly caused by system failures, the patient and, as appropriate, the family, should receive timely, transparent, and clear communication concerning what is known about the event."
4. Institutional Responsibility
Gallagher says institutions are increasingly recognizing that it's not just the responsibility of the individual provider to have these conversations; it's the obligation of the institution.
"It really is the organization that has to have the policies, procedures, training, and support in place to make sure that disclosure conversations are happening when they should, and that they're going well," he said.
5. No- Fault Considerations
There's growing acknowledgement that disclosure and transparency should take place whenever something unexpectedly bad happens, regardless of whether anyone was at fault.
"A fair proportion of medical malpractice lawsuits originate from situations in which there has not been a problem in care, but [because] there was an unexpected outcome coupled with bad communication about it in the aftermath. The patient and family don't understand what happened. They can't get anyone to give them an explanation, and they feel like nobody cares."
6. Better Communication
"Organizations are realizing that what patients want from these situations is often much more than just words," Gallagher says. "We've made the mistake of putting too much focus on what we say to the patient, and not nearly enough on what are the actions that follow. What we are doing to keep this from happening again. And they want to see these changes implemented."