Within the health-care system there is a widespread perception that an adverse event is the result of someone’s mistake. According to the Canadian Disclosure Guidelines, adverse events are “known to most often result from a complex interplay of factors” and are usually identified upon analysis as being caused by a problem within a system or process of health-care delivery. This means that, in most cases, solutions focus on improving systems and processes rather than on individual blame.
The CNA Board of Directors endorsed the guidelinesat their March 2008 meeting. These guidelines support organizations, health-care providers and interprofessional teams in developing and implementing policies and practices for the disclosure of adverse events to patients and their families.
The Canadian Patient Safety Institute led the collaboration among CNA, the Canadian Nurses Protective Society (CNPS) and national organizations representing physicians, pharmacists, other health-care providers and patients to develop the guidelines.
CNA and CNPS worked together to make sure that the guidelines clearly indicate that disclosure is the responsibility of all health-care providers. Generally, no one should disclose an adverse event on their own; the decision about who should make a disclosure will depend on the setting, type of adverse event and policy of the organization.
The guidelines present strategies for disclosure that support good clinical practice, ensure that patients get the information that they need, and improve patient safety. The document is available on the CPSI website at http://www.patientsafetyinstitute.ca/.