Open Disclosure and Anaesthesia

Dr Aislinn Sherwin

Open Disclosure has become a prominent theme in the Irish medico-legal world following the high-profile litigation between Vicky Phelan, the Health Service Executive (HSE) and Clinical Pathology Laboratories. This action triggered a national review and subsequent publication of the Scoping Inquiry into the CervicalCheck Screening Programme by Dr Gabriel Scally in 2018 (1). The report detailed the voluntary nature of the Open Disclosure process in the Irish Health Service, and the paucity of training and audit of Open Disclosure practice among clinicians (2). Open Disclosure involves an open discussion with a patient, and/or their relatives about an incident that resulted in harm to that individual while they were receiving healthcare (3). The elements of disclosure include an apology, an explanation of the event and the follow-up measures to prevent recurrence (3). The benefits of the widespread practice of Open Disclosure are threefold; it improves patient safety by allowing investigation and follow-up of adverse events; it increases trust in the patient and clinician relationship; and facilitates appropriate resolution for patients, their support people and staff members following an incident (5). The Civil Liability (Amendment) Act 2017, protects an apology given by a clinician in an Open Disclosure forum from future use in litigation (4), although the mechanism required to avail of this protection are cumbersome, intrusive, overly-legalistic and rarely used in practice. Anaesthesiology is a unique hospital specialty with practitioners often building a rapport with a patient immediately before anaesthesia. The very nature of our interactions with patients can construct barriers to effective and timely disclosure. A recent analysis of knowledge and understanding of Open Disclosure amongst anaesthesiology trainees in Ireland demonstrated poor understanding of both the concept and practice of the process (6). Barriers to disclosing adverse events mirrored international research and included lack of formal training, lack of organisational support and the prevailing institutional attitude. A culture of judgement and blame within the health service was also highlighted as a barrier. This study also uncovered a reticence amongst Non-Consultant Hospital Doctors (NCHD’s) to submit near-miss or adverse events for discussion at morbidity and mortality meetings suggesting a lack of insight and engagement in a culture of patient safety. Worryingly, many respondents highlighted symptoms of second-victim phenomenon following personal experience of a medical error and were unable to access or locate support when needed.

Currently, Anaesthesiology NCHD’s partake in a professionalism educational program run by the College of Anaesthesiologists in their final years of training, of which Open Disclosure is a component. While the survey demonstrated that trainees are familiar with the concept of Open Disclosure, it is clear that more and earlier education is required on the topic, with further training throughout one’s medical career which could be specific to clinical level. Training within the HSE does exist on Open Disclosure, however a pilot study showed it is not readily accessible or utilised by medical professionals - primarily due to time constraints (7). Recognition of the importance of such training by management, and facilitatory rostering for all medical professionals might improve uptake. As leaders in patient safety, we as anaesthesiologists have a duty to improve our understanding and practice of Open Disclosure. We will also soon have a legal duty to practice Open Disclosure in the event of a medical error. The prospective Patient Safety Bill (2019) before the Oireachtas will legally mandate medical professionals and healthcare institutions to perform Open Disclosure in a list of specific patient safety incidents. It is clear that there is a gulf between the ideal method of Open Disclosure and the current standard that is clinically practiced. Enhanced education, by the medical schools, HSE and the post-graduate training bodies will be necessary to improve the practice of Open Disclosure. More importantly however, a culture change within the broader healthcare organisational environment, from the top level down, is needed to create a sense of psychological safety amongst medical professionals, and thus encourage a duty of candour. We need to move away from a culture of blame and secrecy to benefit our patients, the health service and our profession.


1. Scally G. Scoping Inquiry into the Cervical Check Screening Programme Ireland2018 [cited 2019 05/02/2019]. Available from: http://scallyreview.ie/wp-content/uploads/2018/09/Scoping-Inquiry-into-CervicalCheck-Final-Report.pdf. 2. Learning to Get Better: A progress report. Ireland: Office of the Ombudsman; 2018 [cited 2019 12/04/2019]. Available from: https://www.ombudsman.ie/publications/reports/learning-to-get-better-pr/LearningTGBProgressFINAL.pdf. 3. Executive HS. Open Disclosure Policy: Communicating with Patients Following Patient Safety Incidents Ireland: HSE; 2019 [updated 12/06/2019; cited 2019 12/06/2019]. 2:[Available from: https://www.hse.ie/eng/about/who/qid/other-quality-improvement-programmes/opendisclosure/hse-open-disclosure-full-policy-2019.pdf. 4. The O. Civil Liability (Amendment) Act 2017 [cited 2019 13/03/2019]. Available from: https://data.oireachtas.ie/ie/oireachtas/act/2017/30/eng/enacted/a3017.pdf. 5. Commission CE. Open Disclosure New South Wales: NSW Government; 2020 [18/09/2020]. Available from: http://www.cec.health.nsw.gov.au/Review-incidents/open-disclosure. 6. Sherwin A. LB. Open Disclosure and Anaesthesia [Masters Thesis]. Ireland: Royal College of Surgeons, Ireland; 2019. 7. Pillinger J. Evaluation of the National Open Disclosure Pilot Ireland: HSE; 2014 [01/05/2019]. Available from: https://www.hse.ie/eng/about/who/qid/other-quality-improvement-programmes/opendisclosure/opendiscfiles/evaluation-of-the-open-disclosure-pilot-2016-.pdf.