Study Examines Disclosure of Clinical Adverse Events between VA Surgeons and their Patients
National guidelines recommend full disclosure of adverse events or unanticipated outcomes to patients and family members. There is strong evidence that full disclosure benefits patients and families, and many believe that disclosure is as important for providers as it is for patients because it provides an outlet for the emotional toll providers may experience as part of the adverse event process. VA's handbook on Disclosure of Adverse Events to Patients instructs providers to "provide factual information to the extent it is known, express concern for the patient's welfare, and reassure the patient or representative that steps are being taken to investigate the situation, remedy any injury, and prevent further harm." This prospective study assessed surgeons' reports of disclosing adverse events and aspects of their experiences with the disclosure process. Investigators surveyed surgeons representing 12 surgical specialties (including cardiac, general, neurosurgery, orthopedic, plastics, podiatry, thoracic, and vascular) who practiced at three VAMCs from January 2011 through December 2013. A baseline attitude questionnaire was completed by 67 surgeons, and 62 web-based surveys about disclosure were completed by 35 of these surgeons representing 11 of the surgical specialties. Surgeons were able to complete up to three web-based surveys for three different adverse event disclosures. The survey documented surgeons' experiences of adverse events, their perceived seriousness of the events, and whether they reported discussing the different elements of disclosure (both VA's and the National Quality Forum's [NQF]), with the patient and /or family.
- Surgeons reporting they were less likely to discuss preventability of the adverse event, or who reported difficult communication experiences were more negatively affected by disclosure than others: 60% indicated that the event had moderately, quite a bit, or extremely affected them.
- Most surgeons did not report significant impacts of the event on job satisfaction, confidence, professional reputation, or sleep, but 27% reported anxiety about future outcomes or events.
- Most surgeons utilized five of the eight recommended disclosure items from VA and NQF: 1) why the event happened (92%), 2) expressed regret for what happened (87%), 3) expressed concern for the patient's welfare (95%), 4) disclosed within 24 hours (97%), and 5) discussed steps taken to treat any subsequent problems (98%). Fewer surgeons apologized to patients (55%), discussed whether the event was preventable (55%), or how recurrences could be prevented (32%).
- Quality improvement efforts focused on addressing the association between disclosure and surgeons' well-being may help sustain open disclosure policies.
- This study was limited to surgeons at only three VAMCs.
- Because quality assurance information on adverse events is federally protected, investigators could not capture the range of adverse events occurring. They also could not examine how surgeons in certain specialties are disclosing information.
This study was funded by HSR&D (IIR 07-199). Drs. Elwy, Bokhour, and Glickman and Ms. Zhao and Mueller are part of HSR&D's Center for Healthcare Organization and Implementation Research, Boston/Bedford, MA.
Elwy AR, Itani KMF, Bokhour B, et al. A Prospective, Observational Study of Surgeons’ Disclosures of Clinical Adverse Events. JAMA Surgery. July 20, 2016; ePub ahead of print.