As of January 1, 2017, this policy applies to the operations and staff of legacy UWHC. Effective July 1,
2015, the legacy operations and staff of UWHC and UWMF were integrated into the University of
Wisconsin Hospitals and Clinics Authority (UWHCA). All policies are being transitioned to apply
UWHCA-wide, but until future revision to this policy #4.45, it applies only to the operations and staff of
4.45 Disclosure of Unanticipated Outcomes to Patients/Family
Category: UWHC Administrative Policy
Policy Number: 4.45
Effective Date: January 1, 2017
Section: Legal Affairs (Hospital Administrative)
UWHC encourages staff members to inform patients, and when appropriate their families, about the outcomes of
care, treatment and services, within 24 hours of event whenever possible, in order for patients/families to actively
participate in current and future decisions affecting the care of the patient. While UWHC encourages staff members
to disclose unanticipated outcomes, at a minimum, incidents determined to be Sentinel Events (as defined in
Hospital Administrative policy #4.40-Reporting Unexpected Events & Determination of Sentinel Event Status) must
be disclosed to the patient and family and documented in the medical record.
An "unanticipated outcome" is a result that differs significantly from what was anticipated to be the result of a
treatment or procedure. An unanticipated outcome may or may not include error. A known complication or side
effect is not an unanticipated outcome, but information about such outcomes should also be provided out of
respect for the patient.
When there is an outcome that differs significantly from the anticipated outcome the responsible licensed
professional or his or her designee is encouraged to clearly explain the outcome of any treatments or procedures to
the patient, and when appropriate, to the family. The explanation must occur whenever the incident is determined
to be a Sentinel Event. The responsible licensed professional or his or her designee will provide information about
the outcomes of care. In most circumstances, this discussion will be led by the attending physician.
A. Guidelines for disclosure will focus on:
1. Explain what you know about the event or outcome. Describe only the facts and avoid
2. Always empathize and express regret to the patient (for example, “I'm sorry this has happened
to you”). Apologize if an error has occurred.
3. Explain the patient's current condition, what future developments need to be watched for, what
treatments are or may be needed, etc.
4. Document your discussion with the patient and family. (See 5.1 in the attached guidelines.)
5. The intent of this disclosure is to provide necessary medical information, not to provide the basis
for legal liability. Thus, the disclosure should not place blame or discuss fault. It is not
appropriate to admit or speculate about liability.
6. Commit to follow up with the patient; this may include an explanation of causality regarding the
event or outcome. These subsequent conversations with the patient or family may be necessary
to maintain the relationship and provide information as it becomes available.
B. Confidentiality of peer review processes should be maintained. Patient/families may be told that events
are being looked into, but they should not be told about specific peer review processes and should not be
given official reports of those processes. Support for staff regarding the process of disclosure is available
during work hours by calling Patient Relations or Risk Management Departments and after hours by
paging the attorney on call or the Risk Management Director.
C. Complete required report: Some unanticipated outcomes arise from events (such as medication variances,
patient safety issues, falls, or sentinel events) that need to be reported under the Event Reporting Policy,
#4.22 and those should be promptly made. (Check the guidelines: The attached guidelines are provided
to staff to help them with making appropriate disclosures, and to describe the type of events that may
need to be reported.)
V. RELATED POLICIES
Hospital Administrative policy #4.22-Event Reporting Policy
Hospital Administrative policy #4.40-Reporting Unexpected Events & Determination of Sentinel Event Status
Sr. Management Sponsor: Sr. VP, General Counsel
Author: Manager, Patient Relations
Reviewer(s): Director, Risk Management; Director Nursing,Quality and Safety; Assistant Director, Pharmacy;
Director, Quality & Patient Safety; Safety Oversight Committee; Chair, Dept of Medicine; Clinical Affairs
Committee; General Counsel
Approval Committee(s): Ethics Committee; UW Health Clinical Policy Committee; Medical Board
Peter Newcomer, MD
UW Health Chief Clinical Officer
J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee