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In January 2007, Mary Harney, Minister for Health & Children established the Commission on Patient Safety and Quality Assurance (“the Commission”) and instructed it, among other tasks, to develop clear and practical recommendations which would ensure the safety of patients. In July 2008, the Commission completed its report entitled Building a Culture of Patient Safety. In her foreword to the report, Chairperson, Dr. Deirdre Madden, states: “When such adverse events occur there must be a system in place that ensures that all those affected are informed and cared for, and that there is analysis and learning from the error to try and prevent the recurrence of such an event.”

One of the key recommendations of the report is the development and support of a culture of Open Disclosure to patients and their relatives. Open Disclosure (OD) is defined by the Australian Commission on Safety and Quality in Health Care as “an open, consistent approach to communicating with patients when things go wrong in healthcare.”


In October 2010 the SCA and HSE commenced an Open Disclosure 2 year Pilot project at two sites, the Mater Misericordiae University Hospital (MMUH) Dublin and Cork University Hospital (CUH). The leads in the SCA (Ann Duffy) and HSE (Angela Tysall) developed a 4 hour accredited workshop on open disclosure. Disclosure guidance and national policy were developed by incorporating the learning from the pilot programme while also integrating international learning and best practice guidelines.

An external researcher undertook an evaluation of the pilots between 2014 and 2015. Face-to-face or telephone interviews were held with nineteen managers and healthcare professionals involved in open disclosure in the two pilot sites. One patient representative and thirteen national managers (including the two open disclosure leads in the HSE and SCA) were also interviewed. Three focus groups were held with staff at CUH. An on-line survey was distributed to staff working in CUH and MMUH. There were a total of 339 responses to the on-line survey, of which 211 were from CUH and 128 were from MMUH. The chart on the right represents the respondents by discipline

Figure 1: Breakdown of occupations of respondents to survey

Progress to Date

  1. On 12 November 2013, Dr James Reilly, Minister for Health, launched the State Claims Agency and HSE national policy and guidelines on open disclosure.
  2. Both OD leads have been working with 47 hospitals and in 3 CHOs as part of a change management programme to deliver open disclosure sessions.
  3. Over 400 briefing sessions (approx. 4,000) for all staff and 270 workshops were delivered (approx. 3,000).
  4. Seven “train the trainer” workshops (2 day workshops) with 140 senior staff trained to deliver training within their organisations were delivered.
  5. The external evaluation report will be published in the near future.

The Future

The SCA remains committed with the HSE in ensuring that open disclosure remains a pivotal part of good business within our health services. A strategic approach is now being taken by both Agencies to ensure that OD and the learning opportunities to date influence the healthcare landscape by continuing to inform national policy, under and post graduate education and relevant healthcare organisations.

Article by: Ann Duffy, Clinical Risk Adviser, State Claims Agency

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