Open Disclosure: Ethical and Cultural Considerations

Abstract

While an open disclosure response to major health care error is now regarded as standard and ethical practice, published health care standards or conventions, case law and the literature provide scant guidance about how to respond to incidents where error has gone unnoticed, where a major incident has been averted, where the error is widespread, or where the health practice environment is hostile to an open disclosure approach.

However, by applying a principles ethics approach or a public health ethics approach to case scenarios, it is possible to demonstrate that open disclosure may not always be the best response to any and all kinds of health care error. Asking a series of questions about the setting and severity of health care error will guide health practitioners in determining whether an open disclosure response is appropriate in any given situation. These questions are set out in the Ready Reckoner:

• 1. Are there legal requirements which apply in the jurisdiction – laws, codes, standards, or mandatory policies – which compel open disclosure in response to the health care error in question?

  • If yes, → follow the requirements.

  • If no (near miss, error without harm, error with impact on a community of commonly affected individuals, international setting where there is no law, code, or standard), → question 2.

• 2. Where ethical principles alone guide decision-making, ask:

  Are the social, legal, cultural, and professional conditions conducive to open disclosure?

  • If yes, → consider ethics of open disclosure in relation to the health care error in question by identifying stakeholders and applying a principles approach and/or public health approach and respond informed by this ethical analysis.

  • If no, → question 3.

Where the health care environment is not conducive to open disclosure at all, the response will depend on analysis using an appropriate ethics framework – either principles approach or a public health ethics approach. Where open disclosure to individuals is not possible, consider other actions which promote good and do no or least harm.