Open Disclosure Policy - Victorian Oral and Facial Surgeons

Victorian Oral and Facial Surgeons Open Disclosure Policy

Open disclosure is a discussion between two parties. In small practices, open disclosure is more likely to occur as one discussion (or what, in higher-level open disclosure, would be described as the initial discussion). However, it can also occur through several discussions and meetings.

Open disclosure is a principles-based approach to communicating openly and honestly with patients when things go wrong in health care.

It is grounded in person-centred values, recognising and respecting each individual’s needs, values, and preferences.

The elements of open disclosure are: an apology or expression of regret, which should include the words ‘I am sorry’ or ‘we are sorry’
a factual explanation of what happened
an opportunity for the patient to relate their experience
a discussion of the potential consequences of the adverse event
an explanation of the steps being taken to manage the adverse event and prevent recurrence.

For further information please see: www.safetyandquality.gov.au/our-work/open-disclosure/the-open-disclosure-framework/

Procedure:

Open disclosure should happen as soon as possible after the event has happened. It should occur with the patient and/or family member, the clinician and the practice manager.
Follow the flow chart and framework using the checklist provided for open disclosure of serious/sentinel events.
Information relevant to the process can be included in the checklist to aid the process and facilitate communication between the healthcare team.
All staff involved in the first meeting with the patient must read and agree on the contents of the checklist.

Open disclosure checklist

Checklist	Notes
Patients full name (including title)
Date of birth
Diagnosis, comments and proposed treatment plan
Name/Relationship of family member or carers (if required)
Incident description (known facts only)
Incident outcome (known facts only)
Plan for further investigation and management (report to Department of Health or Coroner)
Has the insurer been notified
Date of first meeting
Location of first meeting
Patient/family members understanding of the incident prior to the first meeting
Person responsible for note keeping
Description of what happened
Apology of expression or regret
Discussion of what will happen next
Information provided about long/short term effects
Information about further support available to the patient
Information how to take it further (if required)
Evaluation and plan

Once the clinical incident has undergone a thorough investigation a process improvement plan is developed with set timelines and nominated responsible people.

All staff members must be involved in understanding the incident, outcome and be part of any training that comes as a result of the improvement plan.