Disclosing Adverse Events in Healthcare: Understanding the Gap Between Knowledge and Practice in Developing Countries

The problem of medical errors and unsafe patient care has gained more attention recently due to increased awareness about adverse health outcomes as well as social and financial impacts. The number of deaths from adverse events and medical errors exceeds that resulting from road traffic accidents, AIDS, and breast cancer.[1] The percentage of patients subject to adverse events while receiving healthcare services is 10% in high income countries and may reach 25% in low- or middle-income countries.[2] A systematic review of studies in developed countries including USA, UK, Canada, Australia, and New Zealand showed that adverse events are a serious problem, with an incidence of 9.2%.[3] Although 80% of adverse events are preventable, unsafe care is one of the 10 leading causes of death and disability worldwide. This is most evident in low- and middle-income countries, with 134 million adverse events reported annually and 2.6 million deaths. The economic burden from adverse events includes up to 15% of direct costs (e.g., increased length of hospital stay and readmissions) in high income countries and 1–2 trillion US dollars annual in indirect social costs.[2]A medical error disclosure is defined as the communication between a healthcare provider and a patient, family member, or patient's legal representative to admit the occurrence of a medical error, including a clear explanation of what happened and how it relates to health outcomes.[4] Although various professional and ethical guidelines, regulations, and laws recommend and organize medical error disclosure practices and policies, healthcare providers find themselves facing a challenging decision in such situations owing to the need for transparency for patient safety guidelines and the fear of negative impacts, like medicolegal concerns and malpractice claims.[4] Healthcare providers, especially physicians, may find difficulty in disclosing medical errors because it requires high level of integrity.[5] In the past 2 decades, many initiatives have been implemented, such as the unanticipated outcome policy of the United States Joint Commission on Accreditation of Healthcare Organization, the disclosure standard developed by the Australian Council for Safety and Quality in Health Care, the duty of condor declared by the UK's National Health System, and the call of the Canada's Royal College of Physicians and Surgeons to promote disclosure of safety issues.[6] In light of increasing malpractice lawsuits, the community and healthcare providers must avoid the shame and blame game and maintain a balance between the need to cultivate a non-punitive approach in dealing with errors and the need to strengthen accountability to ensure fair compensation to affected patients.[6]Developed countries have created and implemented systematic methods to detect, document, and track medical errors including information about the frequency, types of errors, and root causes. This approach facilitates learning from mistakes and continuous improvement. In contrast, healthcare systems in developing countries may lack a systematic approach and suffer from scarcity of accurate information regarding medical errors and adverse events.[7] As a result, there is a lack of locally led research studies in developing countries. Such studies may reflect a more realistic context, including cultural, social, economic, and legal factors that may not be present in developed countries.The paper by Romano and colleagues,[8] recently published in the Global Journal on Quality and Safety in Healthcare, explores the disclosure of adverse events in Brazil, which is a middle-income Latin American country. The authors used an online self-administered questionnaire about disclosure of adverse events with the inclusion of a hypothetical scenario with two different outcomes to compare how healthcare professionals' response can change in severe adverse events causing mortality compared to mild adverse events with little or no symptoms. A convenience sample from healthcare professionals in Brazil was taken with clear efforts to represent different geographical regions in Brazil, age groups, educational levels, and professions in the healthcare system.[8] The results were insightful because most participants (78%) fully agreed that all adverse events should be disclosed, and only 44% believed that the involved healthcare professional should participate in the disclosure process. For the impacts of disclosure on the healthcare institution, 67% of participants agreed that the perception of patients and families can be affected by the disclosure process but only 8% thought that this would diminish trust in the healthcare institution and 11% said that the disclosure may increase the possibility of malpractice lawsuits, especially in severe adverse events leading to mortality or permanent harm.[8]To summarize, Romano et al[8] reported wide agreement that honest disclosure of adverse events is an ethical issue in which there is an immense need for transparency and open communication to promote the trust in the healthcare system. The study highlights the necessity to have institutional policies, standardized guidelines, and formal training to improve the disclosure process, thereby enabling healthcare professionals to deal with such situations in an ethical, professional, and effective way.In conclusion, the paper captured the attitudes and concepts about disclosing medical errors held by healthcare professionals in Brazil, which are affected by the local culture and the relevant laws and regulations. This study is a valuable contribution to the literature for developing countries. Future work might include conducting similar studies in other countries for comparison, perhaps with the addition of qualitative research methods. A comprehensive approach including development of institutional policies and professional guidelines, formal training for healthcare professionals, and continuous monitoring of the culture around research and disclosures at the organizational and national levels is required to overcome the challenges of disclosing medical errors.

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