Open Disclosure

1. Purpose

Southern Eye Centre Day Surgery (SECDS) is committed to open, honest and compassionate communication with patients when an adverse event occurs.

This policy outlines the process for:

  • Communicating with patients and families following an incident

  • Meeting open disclosure requirements

  • Supporting patient-centred care and safety improvement

  • Complying with NSQHS Standards and applicable legislation

2. Scope

This policy applies to:

  • All SECDS employees

  • Medical Practitioners, Anaesthetists and Visiting Medical Officers (VMOs)

  • Contractors

It applies to clinical incidents that result in, or may result in:

  • Patient harm

  • Injury

  • Unexpected complications

  • Significant clinical concerns

3. Policy Statement

SECDS is committed to:

  • Providing timely, honest and respectful communication after an adverse event

  • Acknowledging when care does not go as expected

  • Providing an appropriate apology and explanation

  • Supporting patients, families and staff

  • Using incidents to improve patient safety and prevent recurrence

Open disclosure focuses on learning and improvement, not blame.

4. When Open Disclosure is Required

Open disclosure should occur following:

  • Adverse events causing patient harm

  • Surgical or procedural complications

  • Medication incidents

  • Falls or injuries

  • Equipment-related incidents affecting care

  • Serious clinical incidents

Near misses may also require discussion where appropriate.

5. Open Disclosure Process

Step 1 – Immediate Response

Staff must:

  • Ensure patient safety and provide appropriate care

  • Notify the Medical Practitioner and Director of Nursing

  • Report the incident through RiskClear

Step 2 – Initial Communication

Where appropriate, the treating Medical Practitioner or senior clinician will communicate with the patient as soon as possible.

The discussion should include:

  • Acknowledgement that an incident occurred

  • Expression of empathy and regret

  • Known facts only (without speculation)

  • Immediate treatment provided

  • Follow-up arrangements

Step 3 – Formal Open Disclosure

For significant incidents, a formal discussion may include:

  • Patient and/or family members or support persons

  • Treating clinicians and relevant senior staff

  • Explanation of the review process

  • Findings when available

  • Actions taken to prevent recurrence

  • Written information where required

6. Documentation

Open disclosure discussions must be documented in the patient medical record, including:

  • Date and time of discussion

  • People present

  • Information provided

  • Patient questions or concerns

  • Follow-up plan

Incident documentation must also be completed in RiskClear.

7. Communication Principles

Communication should be:

  • Honest and respectful

  • Clear and understandable

  • Compassionate and empathetic

  • Free from blame or speculation

  • Supportive of patient questions and concerns

8. Patient and Family Support

SECDS will support patients by providing:

  • Information about what occurred

  • Access to follow-up care

  • Interpreter services where required

  • Access to support persons or advocates

  • Information about complaints or feedback processes

9. Staff Support

Staff involved in incidents will be supported through:

  • Clinical debriefing

  • Senior staff support

  • Education and training

  • A culture that encourages reporting and learning

10. Incident Review and Improvement

Following significant incidents:

  • The incident will be reviewed according to severity.

  • Contributing factors will be identified.

  • Improvement actions will be documented and monitored.

  • Lessons learned will be shared through governance processes.

11. Roles and Responsibilities

All Staff

  • Report incidents promptly.

  • Provide safe and respectful care.

  • Participate in reviews when required.

Medical Practitioners

  • Participate in patient communication and open disclosure discussions.

  • Provide clinical explanations and follow-up.

Director of Nursing

  • Ensure open disclosure processes are followed.

  • Monitor incident management and improvement activities.

  • Report significant incidents through governance structures.

Medical Advisory Committee (MAC)

  • Review significant incidents and trends.

  • Monitor improvements arising from adverse events.

12. Training

Staff will receive education regarding:

  • Open disclosure principles

  • Incident reporting

  • Communication following adverse events

  • Escalation requirements

 13. Related Documents 

  • Risk Management

  • Incident Management

  • Complaints Management

  • Privacy Policy

14. References

  • National Safety and Quality Health Service (NSQHS) Standards (2nd Edition)

  • Australian Open Disclosure Framework

  • Victorian Department of Health requirements

  • Applicable Victorian legislation

15. Review

This policy will be reviewed every two (2) years, or earlier if legislation, accreditation requirements or organisational needs change.