What prevents incident disclosure, and what can be done to promote it?

BACKGROUND Adverse-event incident disclosure is gaining international attention as being central to incident management, practice improvement, and public engagement, but those charged with its execution are experiencing barriers. Findings have emerged from two large studies: an evaluation of the 2006-2008 Australian Open Disclosure Pilot, and a 2009-2010 study of patients' and relatives' views on actual disclosures. Clinicians and patients interviewed in depth suggest that open disclosure communication has been prevented by a range of uncertainties, fears, and doubts. METHODS Across Australia, 147 clinical staff were interviewed (mostly over the phone), and 142 patients and relatives were interviewed in their homes or over the phone. Interviews were recorded, transcribed, and analysed by three independent investigators. Transcription analyses yielded thematic domains, each with a range of ancillary issues. RESULTS Analysis of interview transcripts revealed several important barriers to disclosure: uncertainty among clinicians about what patients and family members regard as requiring disclosure; clinicians' assumption that those harmed are intent on blaming individuals and not interested in or capable of understanding the full complexity of clinical failures; concerns on the part of clinicians about how to interact with (angry or distressed) patients and family members; uncertainties about how to guide colleagues through disclosure; and doubts surrounding how to manage disclosure in the context of suspected litigation risk, qualified-privilege constraints, and risk-averse approaches adopted by insurers. CONCLUSIONS Disclosure practices appear to be inhibited by a wide range of barriers, only some of which have been previously reported. Strategies to overcome them are put forward for frontline clinicians, managerial staff, patient advocates, and policy agencies.