“Disclosure is an open discussion with a patient and identified support person(s) about an incident that harmed the patient. It typically involves an ongoing exchange of information over a period of time. Disclosure is not simply a one-way sharing of information. It is intended to be a meaningful dialogue and must include the patient perspective and their experience of the incident.”1
When a practice incident occurs, regulated members must disclose the incident to the patient, their agent, and/or their caregiver. This disclosure will likely need to be supported by conversations among pharmacy team members to better understand the circumstances surrounding the incident. However, if patient safety is at risk, disclosure must begin as soon as possible and the patient must be advised what steps are necessary, including emergency measures, to ensure that harm is minimized.
Even in the event that no physical harm occurs, regulated members should consider the psychological, financial, and social impacts of a practice incident and seek to undertake restorative actions where appropriate.
Disclosure is a process and may occur over a period of time rather than a single interaction. For example, as the pharmacy team learns more about the contributing factors of the incident, they may engage the patient again to provide additional details. This ongoing engagement can restore trust and rapport.
A comprehensive disclosure involves sharing the following information:
Pharmacy teams may be hesitant to apologize to patients when a practice incident occurs. They may be concerned that an apology is an admission of fault or liability; however, a genuine and sincere apology demonstrates compassion, validates the experience of the patient, and helps restore the relationship of trust.
An apology is not considered an admission of liability. In Alberta, Section 26.1(2)(a) of the Alberta Evidence Act (RSA 2000, C.A., 18) states that “an apology made by or on behalf of a person in connection with any matter does not constitute an express or implied admission of fault or liability by the person in connection with that matter” and “shall not be taken into account in any determination of fault or liability in connection with that matter.”2
For detailed advice on disclosure, review the Health Quality Council of Alberta’s “A Guide to Disclosure of Harm” document.
When a practice incident occurs, regulated members must notify any health professionals involved in the patient’s care. Consideration should be given to how and when this notification should occur, based on the severity of the incident and the potential for it to impact the health professional’s ongoing care of the patient.
The pharmacist first confirms with Mrs. Shevchenko that her husband is no longer experiencing symptoms. However, because Farida suspects that a practice incident may have occurred, she asks Mrs. Shevchenko to inspect each box of insulin that was picked up from the pharmacy yesterday. Her suspicion is confirmed: one of the three boxes is rapid-acting insulin. Mrs. Shevchenko describes that the three boxes were taped together and that the box in the middle was incorrect.
Farida explains what she believes has happened and apologizes for the error. Mrs. Shevchenko offers to bring the rapid-acting insulin back to the pharmacy later in the day.
Farida explains, “In the meantime, we are taking this error very seriously and will notify your husband’s doctor of what has occurred. We will also begin our analysis of how this might have happened. Our goal is to make sure it doesn’t happen again. I will update you with more details as soon as we know more.”
Mrs. Shevchenko is thankful for the apology and agrees with the planned next steps.
When a practice incident occurs, the analysis of the event must begin as soon as possible. This process often starts with open and honest communication with the pharmacy team to learn more about the circumstances surrounding the event. The focus of a quality discussion is not to assign blame but, rather, to understand the timeline of events and to dig deeper into the contributing factors and root causes of the incident. The licensee is responsible to ensure this occurs, but any pharmacy team member may initiate it when they become aware of an incident.
Regulated members must use their clinical judgement to balance the urgency of this discussion with the potential for patient harm, in which case disclosure to the patient and necessary clinical follow up should take priority.
The notion of healthcare professionals as second vic¬tims (the patient and their family being the first victims) in practice incidents is well accepted. One systematic review found that physicians involved in medical errors expressed emotional distress that seemed to increase their risk for burnout and depression, potentially leading to an increase in future errors. Substance use, depression, suicide, quitting the medical field, and litigation stress have also been reported as outcomes of practice incidents affecting healthcare professionals.3
Therefore, it is critical that pharmacy licensees, proprietors, and regulated members recognize and mitigate potential psychological harm resulting from a practice incident by offering support. Support can take many forms. The following list of support measures have been identified in the literature,4 in order of importance to healthcare workers:
This list is not intended to be exhaustive, and the measures that are most appropriate or effective in one scenario may differ greatly from those used in another. Pharmacy proprietors and licensees should consider having multiple sources of support available to their team members, and tailor them as required based on the affected individual’s needs. Regulated members must also ensure that confidential patient information is not disclosed with any unauthorized individuals (e.g., family member, counsellor).