Williamstown GP Group is committed to open, honest and transparent communication with patients and their families or carers when things go wrong in the course of healthcare delivery. This policy establishes the practice’s approach to open disclosure in accordance with the Australian Open Disclosure Framework and the RACGP Standards for general practices (5th edition). This policy applies to all members of the practice team at Williamstown GP Group, including general practitioners, practice nurses, and administrative staff.

Open disclosure is the open, consistent approach to communicating with patients following an adverse event or unexpected outcome in their care. It includes an acknowledgement that something went wrong, a factual explanation of what happened, an expression of regret, and a description of steps being taken to prevent recurrence. Open disclosure is not an admission of legal liability.

Williamstown GP Group’s approach to open disclosure is guided by the following principles:

• Openness and timeliness — patients are informed of adverse events as soon as practicable
• Acknowledgement — the practice team acknowledges when something has gone wrong
• Apology and expression of regret — a genuine apology or expression of regret is offered without delay
• Factual explanation — patients receive a clear, honest explanation of what happened and why, to the extent it is known
• Respect and compassion — all open disclosure conversations are conducted with sensitivity and without assigning premature blame
• Support — patients, families and staff involved in an adverse event are offered appropriate support
• Improvement — the practice reviews adverse events to prevent recurrence

Procedure

When an adverse event, near miss, or unexpected outcome occurs in the course of patient care, the following steps will be taken:

Immediate response

The treating GP or practice nurse provides immediate clinical care to address any harm to the patient. The patient’s wellbeing is the first priority.

Notify the Medical Director

The treating GP notifies the Medical Director (Dr Maryam Hosseini) as soon as practicable after the event. If the treating GP is the Medical Director, they may consult a colleague if appropriate.

Open disclosure conversation

The treating GP initiates an open disclosure conversation with the patient and, where appropriate, their family or carer. The conversation will include:

• an acknowledgement that an adverse event has occurred
• an expression of regret for any harm caused
• a factual explanation of what happened and what is known at the time
• information about what will happen next in the patient’s care
• an outline of steps being taken to prevent recurrence

 

The open disclosure conversation, including the date, who was present, what was discussed, and any actions agreed upon, is documented in the patient’s health record in Medical Director. The event is also recorded in the practice’s Significant Event Log.

Follow-up

The Medical Director ensures that appropriate follow-up is provided to the patient and that the practice reviews the event as part of its ongoing quality improvement cycle. Where appropriate, a further conversation with the patient may be arranged once additional information is available.

Support for Staff

Members of the practice team involved in an adverse event may find the experience distressing. The Medical Director will ensure that affected staff have access to support.