TORONTO, March 18 /CNW/ - The Canadian Patient Safety Institute (CPSI)
and the Disclosure Working Group today released the first-ever national
guidelines to assist and support healthcare providers in the disclosure of
adverse events to patients and their families. Experts from organizations
representing physicians, nurses, pharmacists, healthcare providers, patients
and others created the Canadian Disclosure Guidelines through nearly two years
of collaborative effort.
"A focus on patient safety is now emerging in Canada in an effort to
learn from and take coordinated action to reduce preventable harm and death,"
said CPSI Chief Executive Officer Philip Hassen. "CPSI has been pleased to
provide coordination, leadership and funding support to the Disclosure Working
Group, whose tireless efforts to develop the guidelines have resulted in an
important tool for supporting open and transparent communication between
providers and patients."
"The Canadian Disclosure Guidelines are intended to assist and support
the development and implementation of disclosure policies, practices and
training methods. They represent a commitment to the patient's right to be
informed if they are involved in an adverse event, by promoting a clear and
consistent approach to disclosure, emphasizing inter-professional teamwork,
and supporting learning from adverse events."
"The guidelines build on various patient safety initiatives currently
underway across Canada," said Working Group chair Brent Windwick. "Through
them, we hope to encourage healthcare providers to develop or enhance their
disclosure policies and practices by incorporating the core elements, but in
ways that are adapted to their respective needs."
For patients and their families, the guidelines stress the importance of
providing an apology, timely information and access to further health care,
designating a knowledgeable and familiar staff member to provide practical and
emotional support, and assisting patients in accessing additional provider and
"Things can happen with any type of treatment or care, but when they do,
disclosure is very important," said Working Group member and Patients for
Patient Safety Canada member, Katharina Kovacs Burns. "As stressful as this
may be for healthcare providers, who are the ones disclosing, as well as the
patients and families who get the news, apologies are always appreciated.
Apologies are a sign of caring, compassion and empathy, not guilt or blame."
For healthcare providers, the guidelines present clear expectations on
what should be done to disclose information and assist patients and their
families when harm occurs. The guidelines also promote the adoption of a
variety of strategies to make organizational and professional supports
available to providers, as well as discourage speculation or attribution of
"Adverse events affect thousands of patients every year in Canada," said
Working Group member and registered nurse Carolyn Hoffman. "These guidelines
support frontline staff and senior healthcare leaders as they enter into
timely disclosure conversations with their patients. Open and honest
communication following an adverse event helps everyone to learn what happened
and what may prevent the same thing from ever happening again."
"Patients are treated and healed through a relationship with their
healthcare providers that is based on trust and respect," said Working Group
member Dr. Ward Flemons. "When adverse events occur, that relationship is at
risk. Timely, truthful and transparent disclosure can re-establish
patient/provider trust and is always the right thing to do."
Development of the Canadian Disclosure Guidelines
The Canadian Patient Safety Institute (CPSI) was established in 2003 as
an independent not-for-profit corporation, operating collaboratively with
health professionals and organizations, regulatory bodies and governments to
build and advance a safer healthcare system for Canadians. CPSI performs a
coordinating and leadership role across health sectors and systems, promotes
leading practices and raises awareness with stakeholders, patients and the
public about patient safety.
Early in the mandate of the CPSI, five advisory committees were
established to provide feedback and input into strategic initiatives in key
areas of patient safety. The Legal and Regulatory Affairs Advisory Committee
was established under this framework in the fall of 2005. The Committee's
first recommendation was that the CPSI provide leadership and support for the
development of national guidelines for the disclosure of adverse events.
In spring 2006, the CPSI brought together an interdisciplinary team of
Canadian health-system stakeholders to form the Disclosure Working Group with
the mandate to develop national guidelines for the disclosure of adverse
events to patients and their families. The guidelines are intended to assist
and support healthcare providers, interdisciplinary teams, organizations and
regulators in developing and implementing adverse event disclosure policies,
practices and training methods across Canada.
Following a year of collaborative work, which included a national and
international environmental scan and extensive literature review to inform the
development of the guidelines including the professional and legal aspects of
disclosure in Canada, draft Canadian Disclosure Guidelines were developed. The
approach taken in developing these guidelines was to integrate ideas and
concepts from Working Group discussions, expert presentations and stakeholder
consultations. Additionally, a number of local, provincial/territorial,
national and international best practices were reviewed and synthesized.
In May and June of 2007, PRA Inc., an independent research firm retained
by CPSI, conducted a nation-wide consultation process to receive comprehensive
feedback on the draft guidelines. Representatives of targeted healthcare
organizations and groups that represent healthcare professionals and patients
across the country were sent an email invitation to complete a web-based
survey. In total, 187 individuals or organizations responded to the invitation
to participate in the online survey. Additional submissions were also accepted
through direct correspondence with and between member organizations of the
Disclosure Working Group.
In response to the consultation results, the Disclosure Working Group
incorporated further revisions to the draft document. The final document was
approved by the CPSI Legal and Regulatory Affairs Advisory Committee and
adopted by the CPSI Board of Directors in December 2007.
The Canadian Disclosure Guidelines are posted on the CPSI English and
French websites at www.patientsafetyinstitute.ca and
Disclosure Working Group Members
- Brent Windwick, Working Group Chair
- Dawn Vallet, CPSI May/06 - January/08
- Paula Beard, CPSI
- Carolyn Hoffman, CPSI May/06 - September/08
- Elaine Borg, Canadian Nurses Protective Society
- Mike Boyce, Healthcare Insurance Reciprocal of Canada
- Pierre Deschamps, National Council on Ethics in Human Research
- Ward Flemons, Health Quality Council of Alberta (HQCA) from Sept/07
- Ronald Guse, Manitoba Pharmaceutical Association, Canadian Pharmacists
Association, Canadian Society of Hospital Pharmacists, National
Association of Pharmacy Regulatory Authorities
- Beth Kiley, Canadian Healthcare Association
- Katharina Kovacs Burns, Public representation, Best Medicines
- Christina Krause, HQCA representative May/06-Aug/06, Special Advisor
- Susan Kwolek, Canadian College of Health Services Executives
- Patricia Lefebvre, Canadian Pharmacists Association, Canadian Society
of Hospital Pharmacists, National Association of Pharmacy Regulatory
- Mary Marshall, Special Advisor (Legal support)
- Heather McLaren, Manitoba Health
- Jessica Peters, Canadian Council of Health Services Accreditation
- Sylvia Ralphs-Thibodeau, Canadian Nurses Association from Nov/06
- Aviva Rubin, Ontario Ministry of Health and Long-term Care
- Hélène Sabourin, Canadian Nurses Association, May 06-Oct 06
- Jill Taylor, HQCA representative Aug/06-Mar/07, Special Advisor from
- Trevor Theman, Federation of Medical Regulatory Authorities Canada
- Gordon Wallace, Canadian Medical Protective Association
- W. Todd Watkins, Canadian Medical Association
About the Canadian Patient Safety Institute
The mission of the Canadian Patient Safety Institute (CPSI) is to provide
national leadership in building and advancing a safer Canadian health system.
In doing so, CPSI will focus its efforts in three areas:
- Defining patient safety issues in Canadian health care;
- Identifying leading practices and effective interventions; and
- Championing necessary change through partnerships, stakeholder
engagement and transparent communication.
For further information:
For further information: Media Contacts: Jim Durham, Director
Communications, Canadian Patient Safety Institute, Cell: (780) 862-8127,
Toll-Free: 1-866-421-6933; Kelly Bowman, Communications Officer, Canadian
Patient Safety Institute, Cell: (780) 288-3847, Toll-Free: 1-866-421-6933