Caregivers get a new resource for telling patients about unintended harm

Telling a patient that an adverse event occurred, or nearly occurred, during their medical care is difficult for most doctors and healthcare providers. “Adverse event” is a term used to describe unintended harm (or potential harm) to a patient as a result of medical care. Doctors and providers faced with an adverse event might worry how the patient will react, wonder if acknowledging the event will cause legal trouble, or just be unsure about proper reporting procedures. Yet, disclosing adverse events to patients is essential to creating a culture of patient safety in Oregon.

This week, the Oregon Patient Safety Commission released the Oregon Adverse Event Disclosure Guide – a resource intended to help Oregon’s physicians and health care organizations better understand the purpose of disclosure and develop and improve their disclosure programs.

Funded by a grant from The Regence Foundation, the guide provides perspectives and resources to help health care organizations meet Oregon’s requirement that written notification be provided to patients who experience a serious adverse event.

The State of Oregon requires that written notification be provided to patients as a part of its adverse event reporting program. Currently there is compliance about 50 percent of the time. “A crucial component of a culture of safety is a transparent health system where doctors and healthcare organizations are able to effectively share information about adverse events with patients and families,” said Bethany Higgins, executive director of the Oregon Patient Safety Commission. “Written disclosure is only one way of communicating with the patient and should never be the only method used. When leveraged to enhance the oral disclosure process, written notification provides an additional means to build trust and reinforce transparency.”

The disclosure guide was created in partnership with the Oregon Association of Hospitals and Health Systems and the Oregon Medical Association.

“As of September 2011, all 58 of Oregon’s community hospitals are participating in the voluntary reporting program. With full hospital participation, we can work to create a comprehensive perspective about the serious adverse events that occur and how we can learn from each other to improve patient safety outcomes in Oregon,” stated Diane Waldo, director of quality and clinical services for OAHHS. “Reducing hospital-related adverse events is a cornerstone of OAHHS’ quality program and this guide from the Commission assists all hospitals in creating better outcomes for all Oregonians.”

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