Safety and Disclosure
Midwives provide safe and high-quality care to their clients; however, any health care can sometimes result in harm. Harm may be caused by an underlying medical condition or disease, the inherent risk of a specific treatment or a “patient safety incident.” (1) The Canadian Patient Safety Institute (CPSI) categorizes patient safety incidents into harmful incidents, no harm incidents and near misses. Harmful incidents are events that reach the client, such as the administration of penicillin for GBS prophylaxis to a client in labour who has a severe allergy and experiences anaphylaxis. No harm incidents are events that reach the client but do not cause obvious harm, such as the administration of expired IV Penicillin for GBS prophylaxis to a client in labour, when the client and baby remain well in labour and in the postpartum. Near miss incidents are patient safety incidents that are stopped or caught before they occur, such as when penicillin is prepared for a client who has a known allergy, but the allergy is noticed before the infusion is started. (2)
A patient safety incident is the term used to describe “an event or circumstance which could have resulted, or did result, in unnecessary harm to a patient” and can generally be attributed to failure in the complex systems of health care and/or in the performance of providers. (1, 2)
The process of discussing patient safety incidents with clients is called “disclosure” and, depending on the severity of the harm, disclosure may be fairly straightforward or very complex; it may take place once or over a number of conversations. (1, 2)
HIROC, the Canadian Medical Protective Agency (CMPA), the CPSI and the College of Physicians and Surgeons of Ontario (CPSO) address this topic in various comprehensive publications relevant to midwifery practice. Midwives considering disclosure can also seek support and further information from the AOM On Call team. Midwives should contact HIROC as soon as possible regarding any potential disclosure of an event that affects multiple clients (e.g. privacy breaches, sterility lapses).
When to Disclose
When harm is caused to a client, midwives have a responsibility to disclose the incident to the affected client(s). (1-4) In the case of a near miss or no harm event, disclosure is usually indicated, but there may be a situation where it is not. (1, 2) When in doubt, it is best to err on the side of disclosure, even if you don’t think harm was caused. (1, 2) Ask yourself what a “reasonable person” might want to know in the situation, and what you would expect if you were the client. (1) In the context of midwifery care, which typically emphasizes and builds strong relationships of trust with clients over the course of pregnancy, midwives are well positioned to be able to disclose patient safety incidents to their client.
For more information about whether disclosure is indicated for a patient safety incident that you don’t think caused any harm to your client, check out the CPSI Guidelines or call the AOM On Call team.
There are numerous reasons to disclose to a client. Disclosure of a patient safety incident may improve the client’s trust in their care providers and has been associated with decreased rates of litigation. (3) Conversely, clients who feel that their health care providers are withholding information lose trust quickly. (2)
The CMO’s Professional Standards for Midwives requires disclosure “…if a client experienced any harm or injury during your care that is related to your care.” Other midwifery standards indirectly emphasize the importance of disclosure. For example, every midwife is expected to respect their clients’ right to informed choice, advocate for their interests and be honest in all their professional dealings with clients. (4) Clients cannot make fully informed decisions without having access to all information relevant to their individual situation. Upholding the relationship of trust and confidence is another crucial aspect of midwifery care. In general, these standards suggest that all midwives have a responsibility to be open with clients about patient safety incidents, even if no harm occurred. Midwives should carefully consider the consequences of not disclosing a no harm incident, given that the client may subsequently find out that an incident occurred and they were not informed.
The identification of patient safety incidents and the act of disclosure may help prevent the recurrence of similar events, if the practice is able to learn from their experiences and improve their systems. (3) In fact, during the course of a disclosure, clients often want to know what has been changed to ensure a similar incident will not occur again with others. (1)
How to Disclose
Disclosure usually occurs as an ongoing process over time as opposed to a one-time discussion. Clients who receive disclosure will often have complex reactions and questions to ask after the initial conversation. Before providing disclosure, it is a good idea to take time to consider what you will say and who will be in attendance. Reach out to others for support and potential involvement – this might include the AOM On Call team, your midwifery colleagues, elder circle, HIROC or hospital colleagues. (1,2)
Clients generally want to know:
- the facts about what happened
- the steps that have been, and will be, taken to minimize harm
- a sincere expression that the health-care provider and/or organization are sorry for the situation
- a subsequent apology, if a fulsome review finds responsibility ofr the incident (see the CPSI guidance on apologies for more information, starting on page 19)
- what will be done to prevent similar incidents from occurring in the future
- who to contact for more information
- whether a formal review will occur and whether they will be involved
- when the next meeting or communication will occur (2)
Although each sitaution is unique, disclosure generally consists of two components: (1, 2)
The Initial Disclosure
- Occurs as soon as is reasonable
- Focuses on the facts and plan of care
- Usually conducted by the most responsible practitioner (MRP), although others may be in attendance
- Attempts to address the client's informational and emotional needs
- Usually includes an apology
- Provides facts and emotional support but not speculation about "what happened"
- Occurs over time depending on the needs and wishes of the client
- Focuses on conversation about systems, what happened, and what can be changed in the future
- Usually includes a repeat apology
- Includes any new information that has come up during investigation, and any conclusive reasons for harm that have been identified
- Often led by hospital or practice leadership
Any disclosure meetings should be documented in the client chart, including the following details: (1)
- meeting date and time
- who attended
- discussion topics
- reaction and responses of the client
- questions asked and answers provided
- planned next steps
- expressions of empathy
Disclosure in the Context of Midwifery
Midwives may find themselves coordinating a disclosure at their practice or as part of a team at the hospital or birth centre; in this case, practices may wish to consider having one midwife take the lead. This person could also take the lead on quality improvement reviews and handle suggestions and complaints as they occur.
When a patient safety incident involves a group of care providers, it is generally appropriate for one care provider to disclose on behalf of the team. This could be a midwife speaking on behalf of other midwives or might involve an interprofessional care team. Usually, the person selected for this role will be the one most closely involved with the incident. (3) If the client requests that this person does not lead the disclosure, that request should be honoured.
Care providers collectively involved in a patient safety incident should never speculate about other team members’ care or lay blame without a formal investigation. (1) If a care provider has concerns about the care provided by another team member, they should have a direct conversation with the involved party, perhaps with a department head involved, to be well informed of all the details and “in the spirit of learning.” (1)
Midwives may wish to find out more about their hospital processes before a patient safety incident occurs. Midwives who find themselves involved in patient safety incidents, or whose clients have sustained harm as a result of their care, will likely experience a range of emotions. This can be a very stressful situation and midwives may require support from their practice, such as emotional support and time off call. (1,2) The AOM On Call team is always available to provide support and guidance to midwives considering disclosure, whether based at their practice or at the hospital.
- Canadian Medical Protective Association (2017). Disclosing harm from healthcare delivery: Open and honest communication with patients (3rd ed.). Accessed here.
- Disclosure Working Group (2011). Canadian disclosure guidelines: Being open and honest with patients and families. Edmonton, AB: Canadian Patient Safety Institute. Accessed here.
- College of Physicians and Surgeons of Ontario (2010). Disclosure of harm. Policy statement #5-10. Dialogue, 2. Accessed here.
- College of Midwives of Ontario (2018). Professional standards for midwives. Accessed here.
- College of Midwives of Ontario. Professional misconduct regulation. Accessed here.