Disclosure of Information

Overview

Definition

Disclosure of information is the process through which physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship explain clinical information to their patient (or surrogate decision-maker) in a way that the patient/surrogate can understand. 

• It is critical for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship to understand their own clinical situation and make informed decisions about their care. 
• All aspects of a patient’s clinical status should be disclosed and discussed with the decision-maker.
• Underlying principles: autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles,  honesty, transparency

Disclosure of information and informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent

Disclosure of information is a prerequisite for informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent. 

• In order to make an informed decision, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship require all the relevant information necessary to make that choice.
• This information typically includes (but is not limited to):
  • The patient’s diagnosis and prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas
  • Recommended treatment, including side effects and risks of the treatment
  • Alternatives to the recommended treatment, including the risk of nontreatment

Factors in favor of disclosure of information

• Preservation of patient confidence/decreased patient anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder
• Eliminates uncertainty created by doubt (e.g., bad news Bad news Bad news is broadly defined as any information that may alter a patient’s view of their future. Bad news is typically life-changing information that should be communicated to the patient and family with empathy and honesty. Delivery of Bad News is better than “always wondering”)
• Increased patient compliance Compliance Distensibility measure of a chamber such as the lungs (lung compliance) or bladder. Compliance is expressed as a change in volume per unit change in pressure. Veins: Histology and adherence
• Involvement of relatives and caregivers  
• Reduced probability Probability Probability is a mathematical tool used to study randomness and provide predictions about the likelihood of something happening. There are several basic rules of probability that can be used to help determine the probability of multiple events happening together, separately, or sequentially. Basics of Probability of lawsuits

How to Adequately Disclose Information

Setting and timing

• Quiet and private setting; never with other patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship or in a place where one can be overheard
• An adequate amount of time must be allocated for discussion, especially for delicate information; do not rush RUSH Abdominal and cardiac evaluation with sonography in shock (ACES) and rapid ultrasound for shock and hypotension (RUSH) are point-of-care ultrasound (POCUS) examinations indicated in cases of nontraumatic, undifferentiated hypotension, or shock. ACES and RUSH: Resuscitation Ultrasound Protocols the encounter.
• A relative, clergy person, psychologist, and/or social worker may be present to support the patient when discussing serious information.

Who is disclosing the information

• Important information should always be disclosed by the attending physician; e.g.:
  • A new diagnosis (even if this diagnosis is not life threatening or “severe”)
  • Outcomes of a procedure
  • Lab results
• When it is okay to delegate informing patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship of lab results:
  • Always after the attending physician has reviewed the results
  • Information should only be delegated to a trained staff member, typically a nurse.
  • The disclosed information should not alter the plan of care already in place (e.g., informing a patient that their urine culture Urine culture Urinary Tract Infections (UTIs) came back consistent with Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli and the current antibiotic they are on is appropriate therapy).
  • There should always be a way for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship/surrogates to discuss the information being disclosed with their physician should they have questions.

Content

• Relevant information regarding:
  • Diagnosis
  • Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas
  • Recommended treatment
  • Alternative treatments and nontreatment
  • Complications that arise from both treatments and nontreatment
• Information must be disclosed in a way that the patient/surrogate can fully understand. Consider:
  • Language barriers
    • Always have a professional medical translator present for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who speak a different language than the physician.
    • Family members should not be the primary translators (except in emergency situations), as is not possible to guarantee that the information is being properly conveyed to the patient/surrogate
  • Education/mental status/comprehension level of the patient/surrogate
  • Patient’s/surrogate’s hearing or visual impairments
  • Cultural norms

Manner of delivery

• Sensitive, considerate, patient, empathetic, and professional
• The clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship must be aware of proper wording and their own body language.
• Pauses should be provided so that the patient can process the information at their own pace. 
• The clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship must be attentive to the patient’s verbal and nonverbal responses so that the clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship knows when it’s appropriate to pause.
• Clinicians should never lie to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.
• The amount of information should be reasonable; it is appropriate to gently check for understanding.

Disclosure of Medical Errors

Definition

Medical errors Medical errors Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (diagnostic errors), errors in the administration of drugs and other medications (medication errors), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from malpractice in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent. Patient Safety: Types of Medical Errors are defined as either:

• The failure of a planned action to be completed as intended (error of execution)
• Use of the wrong plan to achieve an aim (error of planning) 

A medical error is often defined as a commission or an omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were negative consequences.

Medical errors Medical errors Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (diagnostic errors), errors in the administration of drugs and other medications (medication errors), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from malpractice in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent. Patient Safety: Types of Medical Errors may or may not cause harm to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship directly.

Types of hazards

• Near miss:
  • A patient is exposed to a hazardous situation but does not experience harm, either through luck or early detection of the situation.
  • Indistinguishable from a preventable adverse event, except for the outcome
• Error: refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship to potentially hazardous situations
  • Nonharmful error: An error occurred but did not cause harm. 
  • Harmful event:
    • An error occurred, resulting in harm to the patient.
    • Harm may be mild (temporary mild pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways) or severe (permanent disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment or death).

Common categories of medical errors Medical errors Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (diagnostic errors), errors in the administration of drugs and other medications (medication errors), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from malpractice in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent. Patient Safety: Types of Medical Errors

• Medication events:
  • Administering the wrong medication or the wrong dosage Dosage Dosage Calculation
  • Adverse drug events/reactions
• Healthcare-associated infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease:
  • Catheter-associated urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
  • Ventilator-associated pneumonia Ventilator-Associated Pneumonia Multidrug-resistant Organisms and Nosocomial Infections
  • Clostridioides difficile infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
• Surgical errors:
  • Wrong site
  • Wrong procedure
  • Wrong patient
• Laboratory errors:
  • Wrong test is ordered.
  • Appropriate test is not ordered or results are misapplied.
  • Testing delays
  • Inaccurate results
• Patient falls
• Pressure sores
• Documentation Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature. It often involves authenticating or validating information. Advance Directives errors (e.g., “copy forward” functions with risks for errors; computerized order entries)

How to disclose medical errors Medical errors Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (diagnostic errors), errors in the administration of drugs and other medications (medication errors), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from malpractice in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent. Patient Safety: Types of Medical Errors

The hospital’s internal legal team or risk management team should be notified immediately and can assist in the process of disclosure. With the patient, they should:

• Begin by stating that an error occurred.
  • Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship should disclose both harmful and non-harmful events 
  • Harmful events must be disclosed to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship and families. 
  • Never lie or try to hide a medical error.
  • Disclosing medical errors Medical errors Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (diagnostic errors), errors in the administration of drugs and other medications (medication errors), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from malpractice in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent. Patient Safety: Types of Medical Errors in a timely, professional, empathetic, and transparent manner helps maintain patient/family trust Trust Confidence in or reliance on a person or thing. Conflict of Interest in the system.
  • According to the Code of Medical Ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles of the American Medical Association, “ physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship should at all times deal honestly and openly with patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.”
  • If medical errors Medical errors Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (diagnostic errors), errors in the administration of drugs and other medications (medication errors), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from malpractice in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent. Patient Safety: Types of Medical Errors are not disclosed to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, but later discovered by the patient or family, the patient/family will lose trust Trust Confidence in or reliance on a person or thing. Conflict of Interest in the treating team and is much more likely to take legal action.
• Describe the course of events using plain, nontechnical language.
  • Use clear and concise terms to explain the error to the patient.
• State the nature of the mistake, consequences, and corrective action.
• Express personal regret and apologize.
  • Sincere apologies help patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship understand that their team truly wants the best for them and that the mistake was an honest mistake.
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship prefer apologies over statements of regret; e.g., “I’m sorry I caused you harm,” instead of “I’m sorry this happened to you.”
  • Maintains the physician–patient relationship
  • Decreases the risk of litigation
• Answer all questions and address concerns.
• Plan next steps with the patient.