OpenNotes Patient Safety Initiative

What is it?

With the support of CRICO/RMF, the OpenNotes Patient Safety Initiative is investigating the potential effects of OpenNotes on patient safety.

Safety experts struggle to develop effective ways to reduce error in ambulatory care.  OpenNotes may enhance safety by linking clinicians and patients between visits, times when ambulatory vulnerabilities compound.  They may also offer a unique and readily scalable way to improve quality through a new platform for involving patients in safety.

The initiative includes a broad-based patient survey addressing potential effects of OpenNotes on patient safety.  Survey domains include safety attitudes and ambulatory risk areas (plan adherence, follow up appointments, abnormal test results, persistent but undiagnosed symptoms), accuracy and mistakes in notes, patient willingness to speak up about note errors and concerns, and patient preferences regarding an online patient reporting tool linked to OpenNotes.  The project also involves development and implementation of an online patient reporting tool linked to OpenNotes – among the first in the country – that enables patients and their informal caregivers to provide feedback on the note.  The patient reporting tool highlights the note as a reminder of the visit and takes the next step, asking, “Did we get it right?”

Based at BIDMC, the OpenNotes Patient Safety Initiative is expanding to Boston Children’s Hospital and other interested collaborators nationwide.

Interested in learning more? Check out the OpenNotes Patient Feedback Tool FAQs.

Potential Effects of OpenNotes on Patient Safety

The initiative will also help us better understand how OpenNotes may impact the diagnostic process. We hypothesize that shared visit notes can enhance timely and accurate diagnosis (and safety in general) in several ways, including:

Catching errors in the notes. Documentation errors are particularly prone to propagation in an era of “cut/copy/clone.” Some are trivial and unlikely to affect the patient, but others can have significant impact on patients (i.e., wrong side documentation, etc.). Documentation errors can also affect the diagnostic process if, for example, an inaccurate problem list or family history influences the doctor’s thinking about a particular set of symptoms. OpenNotes have the potential to vastly improve the accuracy of records because they allow one patient to review one chart (his/her own!), rather than relying on one doctor to review thousands of charts.
Preventing diagnostic delay by helping patients better remember recommendations for tests and procedures. OpenNotes fill an important gap by linking the patient with the provider in the time between office visits, a period when delays and lapses can occur. As suggested in multiple earlier studies, patients tell us repeatedly how difficult it is to remember what was said during the visit encounter, especially if they are hearing unexpected or difficult news. Returning to the notes at a later time and in a more relaxed setting, perhaps even sharing the notes with family members or loved ones, can help patients better remember next steps. As one patient attested, “Weeks after my visit, I thought: Wasn’t I supposed to look into something? I went online immediately. Good thing! It was a precancerous skin lesion my doctor wanted removed (I did).” Anecdotal experience suggests also that patients can help remind doctors about follow up diagnostic tests, for example, by alerting a provider to a request a follow up CT scan for an incidental pulmonary nodule.
Helping patients to understand “how the doctor thinks.” In responses to a pilot patient reporting tool inviting feedback on their notes, some patients report that reading their notes enhances their understanding of their doctor’s thought processes. This may help not only with adherence to recommended treatment or testing strategies, but may also enable patients to help doctors avoid cognitive pitfalls, such as diagnostic anchoring, or failure to follow up. For example, if a patient reads in a note that “If the Chest X-ray is negative, we will plan to pursue a CT scan,” s/he can prompt the doctor about this plan, or other downstream “plan B’s,” long after a clinician may lose track of details (especially related to normal findings).
Encouraging patients to speak up about ongoing, undiagnosed symptoms. Here we distinguish between two at-risk categories: patients with symptoms that do not improve despite a prescribed treatment, and patients with symptoms that persist despite negative or inconclusive tests/ studies. In both cases, we anticipate that reading the note can help educate and empower patients to return to their providers with questions: “This plan we discussed doesn’t seem to control my symptoms/provide an answer. What is next?” Barriers to speaking up abound, but taking a first step by sharing notes with patients sends a strong message of transparency and inclusivity. Additional educational strategies might strengthen the invitation by inviting patients explicitly to participate actively as advocates for safety in their own care.
graphics for safety toolkit
Patients, OpenNotes, and CRICO sharing ideas on patient safety
Engaging informal caregivers. OpenNotes can uniquely benefit informal caregivers, those tasked with caring for chronically ill and vulnerable patients with complex medical problems. It is not uncommon for such care to be delivered through multiple providers, perhaps even at multiple centers, with variably effective coordination of care. OpenNotes can serve as a “hub” among these different providers, helping informal caregivers stitch together different plans, treatment changes, and recommended studies/tests, potentially reducing redundancies and identifying conflicting information or gaps in diagnostic processes.
Enhancing trust. Sharing visit notes can enhance patient trust. As one patient commented: “I saw that my doctor truly listens to what I have to say,” Another noted, “I respect, trust and appreciate her even more.” For those diagnostic processes that are not straightforward, intangible characteristics reflecting a strengthened patient-doctor relationship may help stem “doctor-hopping” or fragmented care that can jeopardize timely diagnosis.


The Patient Safety Story Today

The OpenNotes patient safety story is rapidly evolving. OpenNotes has already been supported in two landmark statement papers (Shining a Light: Safer Healthcare Through Transparency & Safety is Personal: Partnering with Patients and Families for the Safest Care) by the National Patient Safety Foundation and Lucian Leape Institute, with a call to action to provide OpenNotes to patients at large.



OpenNotes was awarded the John Q. Sherman award for patient engagement at the 2014 annual National Patient Safety Foundation Congress.

Solicited by the Institute of Medicine (IOM), we have participated in contributions to the IOM report on diagnostic errors, and how OpenNotes may help prevent such mistakes.

A discussion of potential effects of OpenNotes on patient safety (and institutional disclosure, education, and patient engagement programs) can be found in the August  2015 issue The Joint Commission Journal on Quality and Patient Safety.   

Interested in learning more or collaborating with the OpenNotes Safety Initiative?

Please contact Macda Gerard at