Standards › Standard BASIS › Policies
Policy · CAN-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: B2.14
At a glance
- When a patient is harmed by their care, the facility tells the patient, and where appropriate their family, promptly.
- The disclosure explains what happened, what is known so far, what will be done, and includes a clear apology.
- The disclosure is recorded, and a written summary follows within the timescale set by the governing body.
- Staff involved in the harm are supported, and disclosure is never delayed to protect the facility.
- Stop and get help straight away if: a patient harmed by care is not told, or a disclosure is made with no apology and no account of what happens next.
1. Purpose
To make sure patients and their families are told openly and promptly when they are harmed by care, and receive an apology and a clear account of what will happen next (B2.14).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Harm | Any unintended or unexpected injury or harm to a patient caused by their care, that results in or may result in a need for further treatment, extra time in care, or lasting effect. |
| Disclosure | The conversation in which the facility tells a patient or family what happened, and what it will do. |
| Apology | A clear statement that the facility is sorry that the harm happened. It is not an admission of legal liability and is not withheld for that reason. |
| Responsible clinician | The clinician with the most direct knowledge of the care, who leads the disclosure with the support of a manager. |
4. Background
To make sure patients and their families are told openly and promptly when they are harmed by care, and receive an apology and a clear account of what will happen next (B2.14).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Makes sure the policy is followed, reviews every disclosure each quarter, and reports to the governing body | Governing body |
| Responsible clinician | Leads the disclosure conversation, apologises, and writes the summary | Clinical director |
| Ward or department manager | Supports the clinician, arranges the meeting, and records the disclosure | Clinical director |
| Quality lead | Keeps the disclosure register and checks timescales | Clinical director |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Identify.
- Within the incident review, classify each incident that caused harm to a patient.
- Tell the clinical director the same day for any serious harm.
Key point: Harm identified.
Step 2. Plan.
- Name the responsible clinician and the manager who will support them.
- Arrange a private meeting at a time the patient and family can attend, with an interpreter where needed.
Key point: Meeting planned.
Step 3. Disclose.
- Explain what happened, what is known so far, and what the facility will do next.
- Give a clear, sincere apology, and invite questions.
- Record the date, the people present, what was said and the questions asked.
Key point: Disclosure made and recorded.
Step 4. Write and follow up.
- Send a written summary to the patient within the timescale set by the governing body, and in any case within 10 working days.
- Record the summary date in the disclosure register (CAN-REG-001). Review what was learned at the next quality meeting.
Key point: Summary sent and follow-up recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Harm incidents with a disclosure record | 100% | Quarterly | Clinical director | Escalate to the governing body |
| Disclosures made within the set timescale | 90% or more | Quarterly | Quality lead | Review the process with the managers involved |
| Disclosures with an apology and an account of next steps | 100% | Quarterly | Clinical director | Retrain the clinicians involved |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Clinicians complete training in communicating harm and apology at induction and every two years.
- Staff involved in a harmful event are offered support, and the offer is recorded.
16. Related documents
| ID | Title | Use |
|---|---|---|
| CAN-REG-001 | Harm disclosure register (existing) | Register |
| TRM-SOP-001 | Disclosure of evidence to patients (existing) | SOP |
| HH-POL-001 | Hand Hygiene Policy (existing) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
No e-learning course is linked to this document yet.
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)