Clinicians involved in incidents where patients are harmed do not go unaffected from the experience. In addition, when a practitioner makes an error work colleagues are often affected through witnessing what they go through (Hall & Scott, 2012; Wu, 2000; Wu & Steckelberg, 2012).
The term second victims is used to describe the suffering experienced by clinicians involved in a patient safety event (Nelson & Beyea, 2009). Clinicians often suffer similar emotions to the first victims (the patient and their family) with some health care workers leaving the profession and a small few committing suicide (Wu & Steckelberg, 2012). One study found that one in seven staff who had experienced a patient safety event within a twelve-month period had suffered anxiety, depression or had doubts about their ability to do their job well (Hall & Scott, 2012).
Associated with this is the issue of being open with patients and/or their families if an error occurs. With a growing impetus to incorporate disclosure as an essential part of managing adverse events there is also a need to ensure that clinicians are supported as well as the patient and their families. (Wu & Steckelberg, 2012). Despite fears of litigation (Studdert & Richardson, 2010; Haw et al., 2014) it has been identified that the risk of this occurring is reduced if there is openness when an error occurs (Gallagher et al., 2007).
Just as there are multiple definitions for the term error there is also difference associated with the term disclosure. This, along with a brief overview of the law, will now be considered.
A published review of the literature on disclosure found that policies in relation to dealing with adverse events with openness used a variety of terms such as duty of candour, full-disclosure and disclosure of harmful errors (Allen & Munro, 2008). Although terminology and language differs, the policies and definitions work
27 towards a common goal of dealing with a patient and/or their family when an adverse event occurs.
A more recent systematic review found a gap between the ideal practice of disclosure and what really occurs (O'Connor, Coates, Yardley, & Wu, 2010). It was also noted that the bulk of research on disclosure is related to the experience of physicians despite health care being delivered by multi-disciplinary teams.
For this research use of the term open disclosure is defined as “an open discussion with a patient about an incident(s) that resulted in harm to that patient while they were receiving health care” (Australian Commission for Safety and Quality in Health Care, 2013a, p. 4). The Australian Open Disclosure Framework outlines that for open disclosure to occur there should be an apology, provision of the facts regarding the events leading to the harm and an explanation of what will be done to manage the situation along with information about what is being done to ensure a similar situation does not arise again. The patient also needs to be given an opportunity to put forward their own experience. This process may occur over more than one meeting.
For the purposes of this research the term open disclosure will be used when referring specifically to this definition as provided within the Australian Open
Disclosure Framework (Australian Commission for Safety and Quality in Health Care, 2013a). The term disclosure will be used in reference to the acknowledgment to a patient and/or their family that an error has occurred.
In Australia a nurse is mandated to report if he or she has any serious concerns relating to care delivery patients may have received from other health care workers (Australian Health Practitioner Regulation Agency, 2010). They also have to balance their duty of care to the patient (also legally mandated) with their duty to the team, their organisation and their personal interests (Harrison et al., 2014).
28 The open disclosure of error is also required as part of the hospital accreditation process. Standard 1.16 of the National Standards requires a program is in place that is based upon the national open disclosure standard (Australian Commission for Safety and Quality in Health Care, 2011a; Australian Commission for Safety and Quality in Health Care, 2013a).
Within the Australian context it has been noted the laws associated with disclosure have not been developed with disclosure in mind and they have been described as offering “weak” protection for clinicians (Studdert & Richardson, 2010). It is not only a fear of medico-legal consequences but also a lack of education and training in the skills required to undertake the process that is a barrier (Studdert & Richardson, 2010).
An example of this is apology laws. Clinicians in some states who apologise for an error are protected from the use of that apology in any subsequent litigation. Other states, of which Tasmania is included, either do not offer this protection or any admission of fault is excluded from what constitutes an apology (Australian Commission for Safety and Quality in Health Care, 2012a; Studdert & Richardson, 2010). As a result there is a conflict between what the system expects by way of protecting the public compared to what is offered with respect to the protection of clinicians.
There are some who argue that protection of the public does not go far enough and that the duty to disclose should be mandatory. A case heard in the European Court of Human Rights found that there was no statutory requirement for medical
professionals to inform patients when errors occur (Powell, 2014). This has sparked debate around the need for mandated duty of candour (Birks, 2014; Francis, 2014; Powell, 2014). A legislative requirement such as this would put the accountability upon the individual and it is not clear if such an approach would be effective. There are arguments that the accountability for error disclosure should be maintained as an organisational a systems focus rather than placing responsibility for disclosure at the level of the individual. (Harrison et al., 2014).
29 It is issues such as these that create tension between what is expected of clinicians and what they are able to undertake in the day-to-day reality of practice. This underlying complexity makes it difficult to ensure that error is always appropriately dealt with within the health care system.