Patient Safety Disclosure
Initial disclosure
As soon as possible, and within 24 hours of the patient safety incident, the most responsible practitioner for the patient who experienced a safety incident and if appropriate, the most appropriate operational leader, explain the known facts of the incident to:
- the patient;
- if the patient does not have capacity, to the patient’s substitute healthcare decision maker (SDM); or
- if the patient has died, to the family.
Present the nature, severity and cause (if known) of any harm in a straightforward and non-judgmental manner, avoiding speculation, opinion and blame.
Explain that there may not be answers all the questions asked but rather, only what is known at the time of the discussion is disclosed. Commit to providing additional disclosure of facts as they become available.
Disclose what further medical attention is required, if any.
Seek assistance from others as appropriate. This may include:
- describing what, if anything, can be done to correct the consequences of the
incident; - offering a second opinion, the involvement of outside assistance, or
- transfer of care to another practitioner.
Offer a copy of the health record with the access fee waived.
The most responsible practitioner offers to review the copy of the health record with the patient/SDM/family.
If a patient does not want to receive information about the patient safety incident, the most responsible practitioner for the patient who experienced a safety incident records the waiver of disclosure in the patient’s health record.
Resource: Disclosure of Patient Safety Incidents Policy – Section 3.8
Post analysis
Critical Incidents as per The Critical Incident Regulations, 2023:
An incident that arises as a result of the provision of a health service by the SHA or a health care organization (HCO) and which is a serious adverse health event that:
- occurred while receiving a health service provided by, or a program operated by, the SHA or an HCO;
and was not expected or intended to occur; and is serious and undesired, such as:- death, disability, injury or harm, or
- unplanned admission to a health facility or an unusual extension of a stay in a health facility, or
- a significant risk of substantial or serious harm to the safety, well-being or health of the patient, and
- does not result primarily from the individual’s underlying health condition or from a known risk inherent
in providing the health services
Following a Critical Incident review, the Manager, Patient Safety & Client Concerns will provide the most responsible practitioner and if appropriate, the most appropriate operational leader with information to be disclosed to the patient/SDM/family.
The most responsible practitioner and if appropriate, the most appropriate operational leader leads the post-analysis disclosure.
What can be disclosed based on legislation and legal privilege?
- new facts and actions taken, or intended to be taken, for improvement
- new facts
What cannot be disclosed based on being protected by legal privilege, which means it can not be used
in legal proceedings?
With respect to Critical Incidents:
- Critical Incident Notices;
- Critical Incident Reports;
- Any information in a Critical Incident notice or report;
- Any documentation used to prepare a Critical Incident notice or Critical
Incident report.
Quality Improvement Committee
A Quality Improvement Committee (can be a Committee of one or more) carries out a quality improvement activity the purpose of which is to examine and evaluate the provision of health service for the purpose of educating persons who provide health services, or improving the care, practice or services provided to patients by the SHA.
All Quality Improvement Committees presently established and to be established within the SHA by the SHA and SHA administration are designated by the SHA Board as Quality Improvement Committees for the purposes of section 10 of The Evidence Act.
What cannot be disclosed based on being protected by legal privilege, which means it can not be used
in legal proceedings?
With respect to Quality Improvement Committee:
- any report, statement, memorandum, recommendation, documentation, information, data, or record that is prepared exclusively for the use of or made by a Quality Improvement Committee; or
- is used exclusively in the course of, or arises out of any investigation, study or program carried on by a Quality Improvement Committee.
Resource: Disclosure of Patient Safety Incidents Policy – Section 3.12