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Gallagher, TB, S. K.; Smith, K. M.; Mello, M. M.; McDonalad. T. B. (2009) Disclosing harmful medical errors to patients: tackling three tough cases. Chest 136:897-903.
Iedema, R, Allen, S, Britton, K, Grbich, C, Piper, D, Baker, A, Allan, A, Jones, L,
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Disclosure – the ʻ100 Patient Storiesʼ qualitative study. British Medical Journal 343.
Iedema, R, Allen, S, Sorensen, R, and Gallagher, TH (2011b) What prevents the disclosure of clinical incidents and what can be done to promote it? US Joint Commission on Quality & Patient Safety 37:409-417.
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Conclusion
The domain of incident disclosure has seen a rapid increase in interest from policy makers, researchers, clinicians, consumers and even insurers. The above literature review provides but a snapshot of some of the more notable works published in this domain. Nevertheless we are able to deduce some important conclusions from the literature review. Three conclusions are outlined here.
First, incident disclosure is recognized to realise patient-centredness. Without adequate communication about unexpected outcomes, and without that communication being structured as open and democratic dialogue, patients are unlikely to derive the feeling their interests and concerns are heard. Since it is their bodies that are ‘on the line’, and some rare exceptions aside, non-disclosure is no longer feasible or ethical.
Second, incident disclosure is increasingly realised to encompass more than ‘just’
disclosure of an incident. Thus, disclosure is seen as indicator of safety culture. Going beyond obligation to the patient (or their family), open discussion about unexpected outcomes manifests practitioners’ and services’ resilience in the face of problems and failures. It demonstrates their capacity for learning, and it evidences a humility towards those who seek care.
Third, incident disclosure is regarded as requiring innovative ways of thinking about (the need for) legal reform. Useful examples can be found in the domains of family law and public accident and disability insurance. There, we have complemented adversarial and complaints models with elaborate conciliation processes and public insurance
arrangements. These arrangements provide important starting points for rethinking the ways in which we currently frame health care incident responses, and for re-evaluating our approach to legal reform.
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