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To the Editor. Original article published in "Mitchell, Geoffrey, Willmott, Lindy, White, Ben, Piper, Donella, Currow, David, & Yates, Patsy (2019) A perfect storm: fear of litigation for end of life care. Medical Journal Of Australia, 210(10), p. 441. "

Objective: To analyse rural patients' and their families' experiences of open disclosure and offer recommendations to improve disclosure in rural areas. Design: Retrospective qualitative study based on a subset of 13 semistructured, in-depth interviews with rural patients from a larger dataset. The larger data set form a nationwide, multisite, retrospective-qualitative study that included 100 semistructured, in-depth interviews with 119 patients and family members who were involved in high-severity health care incidents and incident disclosure. The larger study is known as the '100 Patient Stories' study. Interviews were transcribed verbatim and analysed by one analyst (D.P.) for recurrent experiences and concerns. Setting: Acute care. Participants: A sub-set of 13 of the 100 participants from the '100 Patient Stories' study who identified as experiencing an adverse incident in a rural or regional area. Main outcome measures: Patients' and family members' perceptions and experiences of health care incident disclosure, as expressed in interviews. Results: Rural patients and clinicians experience additional challenges to metropolitan patients and clinicians in their experiences of health care incidents. These additional barriers include: a lack of resources at small hospitals; delays in diagnosis and transfer; distance between services; and a lack of communication between providers. These challenges impact not only upon how patients and their families experience incidents, but also how open disclosure is implemented. Conclusions: This analysis of 13 of the 100 Patient Stories interviews provides guidance to rural health services on how to conduct open disclosure.

Objectives To understand patients' and health professionals' experience of Open Disclosure and how practice can inform policy. Background Open Disclosure procedures are being implemented in health services worldwide yet empirical evidence on which to base models of patient-clinician communication and policy development is scant. Design, setting and participants A qualitative method was employed using semi-structured open-ended interviews with 154 respondents (20 nursing, 49 medical, 59 clinical/administrative managerial, 3 policy coordinators, 15 patients and 8 family members) in 21 hospitals and health services in four Australian states. Results Both patients and health professionals were positive about Open Disclosure, although each differed in their assessments of practice effectiveness. We found that five major elements influenced patients' and professionals' experience of openly disclosing adverse events namely: initiating the disclosure, apologizing for the adverse event, taking the patient's perspective, communicating the adverse event and being culturally aware. Conclusions Evaluating the impact of Open Disclosure refines policy implementation because it provides an evidence base to inform policy. Health services can use specific properties relating to each of the five Open Disclosure elements identified in this study as training standards and to assess the progress of policy implementation. However, health services must surmount their sensitivity to revealing the extent of error so that research into patient experiences can inform practice and policy development.