Article Excerpt — Disclosing Errors to Patients: Perspectives of Registered Nurses
Excerpted from Shannon, Sarah E.; Foglia, Mary Beth; Hardy, Mary; Gallagher, Thomas H. Joint Commission Journal on Quality and Patient Safety, Volume 35, Number 1, January 2009, pp. 5-12(8) 
 
POLICIES MIGHT HELP
Although each of the four organizations in which study participants worked had formal policies related to disclosure of medical errors, many nurses in these 11 focus groups were unaware of the existence or contents of these policies. Nurses observed that their organizations had innumerable policies and that it was impractical for them to know the specific content of each. Other nurses were skeptical about the influence of formal policies on disclosure practices, in part because the issue of whether to disclose was perceived as dependent on contextual factors and therefore was not amenable to clarification through a detailed procedure. Finally, nurses noted that the simple existence of a policy did not ensure that appropriate disclosure practices would follow: “If staff want to hide an error, the nuances of policy will allow them to justify it in their minds and they just won’t tell anybody.”

In spite of a general lack of knowledge of their sites’ disclosure policy, some nurses thought that organizational policies could promote more transparent practices if they provide a framework and guidelines for error disclosure (that is, as opposed to a detailed, step-by-step procedure) that include a process that promotes direct communication between nurses and physicians involved in a specific event. Disclosure policies that articulate a role for nurses were perceived by participants to provide them with the authority to proactively initiate a team process for planning and conducting the disclosure. They suggested that this authority was particularly important in situations where disclosure to the patient was contested (for example, disagreement among members of the health care team) or in the predisclosure period, when the patient or family were asking the nurse probing questions: I think we need a process of how to address concerns amongst the team…Like say there was something funny going on in the OR and your patient comes out. If you had a policy of saying, ‘I would like to call a meeting with the team, including the doctors, because the family is asking me a lot of uncomfortable questions.’

IT ALL DEPENDS ON YOUR NURSE MANAGER
Participants across all focus groups emphasized the pivotal role of the unit’s nurse manager on disclosure practices among nursing staff. These nurses often discussed reporting and disclosing as components of a single integrated process rather than as separate or discrete practices. Transparency began with revealing the error to one’s supervisor, nursing colleagues, and the patient’s physician, often involving formal reporting followed by disclosure to the patient. When frontline managers approached errors from a systems perspective rather than as an individual failure, these focus group participants were not reticent to reveal their errors.

Conversely, nurses who believed that their nurse managers had unfairly blamed or shamed individual staff nurses regarding errors were ambivalent about revealing future errors. In one focus group, participants recounted a situation in which a nurse was admonished for disclosing an error to  patient, leaving the participants with the belief that nurses were being discouraged from acting on their moral duty to tell patients the truth.