What’s New in the Patient Safety World

June 2012

Oregon Adverse Event Disclosure Guide



Disclosure and apology after adverse medical events have become the recommended actions (see the links to multiple columns on disclosure and apology at the end of today’s column). There have been many excellent resources on disclosure and apology, including:

·        IHI’s “Respectful Management of Serious Clinical Adverse Events” (Conway 2010)

·        The Canadian Disclosure Guidelines (Canadian Patient Safety Institute 2008)

·        The Harvard Disclosure Guidelines (Massachusetts Coalition for the Prevention of Medical Errors 2006)

·        The ACPE Toolkit (American College of Physician Executives)


Now the Oregon Patient Safety Commission has developed the Oregon Adverse Event Disclosure Guide. Oregon is one of the states with laws governing disclosure and some degree of legal protection in the disclosure process. The Guide has a good discussion on the goals of disclosure. Disclosure is not just to satisfy the state’s legal requirements. Rather it is to demonstrate empathy and respect for the patient, increase trust between the providers/healthcare system and the patient, family, and community at large, enhance accountability and transparency, give patients and families an opportunity to understand what happened, and demonstrate to employees the organization’s commitment to safety and quality. Additionally, disclosure may have a positive impact on both litigation outcomes and media attention. They recommend disclosure not only in those adverse events defined by statute but even in those cases where no patient harm occurred and sometimes where no errors occurred.


The Guide recommends oral disclosure followed by written disclosure. They strongly recommend that the initial disclosure always be done in-person but that the written disclosure be used to enhance, not replace, that in-person interaction.


The best part of the Guide is its terrific set of links to other resources. While they provide links to all the valuable resources we’ve mentioned above, they also provide links to sample disclosure policies, letters, work plans, and tools to improve the ability of providers to do disclosure in the proper, empathetic manner.




Some of our prior columns on Disclosure & Apology:

July 24, 2007               Serious Incident Response Checklist

June 16, 2009              Disclosing Errors That Affect Multiple Patients

June 22, 2010              Disclosure and Apology: How to Do It

September 2010           Followup to Our Disclosure and Apology Tip of the Week

November 2010           IHI: Respectful Management of Serious Clinical Adverse Events

April 2012                    Error Disclosure by Surgeons







Oregon Patient Safety Commission. Oregon Adverse Event Disclosure Guide. A Resource for Physicians and Healthcare Organizations. 2012
















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