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Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study

BMJ 2011; 343 doi: (Published 25 July 2011) Cite this as: BMJ 2011;343:d4423

Rapid Response:

Solving the incident disclosure problem: a default form approach.

We can all definitely say that there is an evident and notable
problem in world health care between some physicians and patients in the
realm of communication, with incident disclosure being one of them. It is
definite stressful and confusing to be a patient or family member and not
know what happened during a specific incident, why it happened, or to only
know half of the story. It is my opinion that if the gap in communication
is closed, patient quality of care can be enhanced. I believe that it is
because of this lack of understanding about what happens or has happened
at hospital stays or healthcare team contacts that many patients have
negative views about quality of care. A majority of patients feel
confused, anxious, or uncertain about care when things they don't know
about happen. A common example of this is seen in surgery. We often hear
clinicians use the phrase, "there were some complications, but, overall,
the surgery went well." To a patient, this is both a sigh of relief and a
cause of anxiety. The patient is happy that the surgery went well, but
they are immediately put off by the fact that complications happened. The
patient wants to know what the physician means by complications, and how
severe the complications were. Another example of the communication
barrier is in "Code Blue" situations. Often times, the patients family, or
the patient themselves, never finds out what exactly happened, what was
done about it, and why certain things were done. This leads to negative
views on their care during this crisis. There are many possible ways to
overcome this problem, such as physician contact, customized patient
education material, full disclosure of the incident via written medium by
administrative members, or a combination of these. However the immediate
problem arises in that some of these are not feasible because of time
constraints, HIPAA and other PHI law, or other problems. It is my belief
that the best way to create patient understanding while being minimally
intrusive to physicians is to take advantage of Incident Form-like
written material.

Most nurses that have worked at hospitals or nursing homes have seen
their fair share of Incident Forms. They are a default form used when
something happens to a resident that needs to be noted, such as a fall,
new skin lesion, accidental exposure to various disease, or even needle
sticks. A sample form can be found here: (link to a
.DOC text document). Of course this form would have to be customized for
the purpose of incident explanation for patients and patient family. It
would have to be simple, easy to understand, and easy to fill out. It
should include what exactly happened, what was done about the incident,
and why that was done. This information should be concise, simple, and to
the point, but be quality enough to assist the patient in understanding
the entirety of the incident. To ensure the best possible use of this
form, it should be accompanied by a short physical contact from the
physician, as soon as possible after the incident, to answer any questions
or concerns from the family or patient. If possible, the patient or family
should be given a copy of the form for their records, and for them to
review if they doubt or question anything about the incident. If the
physician agrees, it would be a good idea to include a phone number and
time that the physician can be contacted if any other questions arise.

Doctors and clinicians would argue that this simply creates more
paperwork, while providing no more information than could be conveyed
during a physical contact. To ease these concerns it would be wise to make
the report as simple and concise as possible while maintaining patient
understanding, and also to make this easily available to the physician.
Doctors are generally busy people, and do not need to be hunting down
forms and filling out long, strenuous documents. It is for that reason
that I recommend making the document easily accessible, and "short and
simple" as they say. In regards to being forced to give documentation
about why the physician made certain decisions, it may be wise to provide
common instruction to all doctoral staff of sample formats, such as using
reference to past teaching to justify current practice. An example of such
would be, "In medical school, we were taught that the best way to treat an
open wound from a fall was to clean the wound with a common disinfectant,
such as Hydrogen Peroxide, close the wound if needed, and dress the wound
to provide against infection." This sample response provides the patient
with ease by referencing past knowledge, and showing the patient your
reasoning behind the decision. It is surprising to find out that most
people who question what a physician does in an acute incident are more
curious about the idea behind the action than the actual action itself.
What I mean by that is that the patient is more interested in the thought
process behind why you decided to simply clean and dress the wound, than
the patient wants to doubt or question your actions. However, in order to
maximize the effectiveness of the default form approach to incident
disclosure, the physician or clinician also needs to look at it from the
patients point of view.

As a patient, or patients family, that has been on the "receiving"
end of an incident, their primary concern is achieving peace of mind in
simply knowing what happened. The advantage of the default form approach
to incident disclosure is that it allows the patient or family to process
the information in visual manner. The patient is able to visual the
incident and process the information at will, rather than having to
process it as it is spoken to them. While this may seem like a very small
advantage, it is a huge change in the understanding of the information. A
clinician may liken this experience to a professor simply lecturing a
class, with no book or visual material to assist. The physician would not
remember the information for as long, or with as much accuracy as they
would if they were able to "see" the information in a book or visual
medium. With this thought it is very easy to realize the vast effect of a
written form to assist patients in understanding. Another major advantage,
mainly in giving the patient a copy of the form, is that the patient can
refer to the information any time they have questions or doubt what was
said. It allows them to refresh the data in their mind and answer new
questions that may arise.

Obviously there are both advantages and disadvantages of a default
form approach to incident disclosure, however I feel that this approach
offers the most assistance to both the physician and the patient, while
producing the least obstructive change to the physicians practice. This
approach is designed to foster understanding and communication between the
physician and patient, and provide the patient with a reference for
questions and concerns. It is also minimally obtrusive financially to the
healthcare field, that being a major plus in the times that we live. Again
you must understand that this is just one approach to incident disclosure
and communication between physicians and patients/family, however I feel
it is the best approach.

Competing interests: No competing interests

26 July 2011
Chester E. Taylor
Medical Assistant and Pre-Medicine student
Murray State College