Patient-reported errors relate most commonly to diagnoses, medical history, and medications
Boston, MA – A new report led by OpenNotes investigators published in the Journal of the American Medical Association (JAMA) Network Open suggests patients could play a critical role in identifying important errors in their medical records.
Analysis of 22,889 survey responses in three U.S. health systems from patients who read their clinicians’ visit notes online revealed that 1 in 5 had perceived at least one mistake in their notes. This large study suggests that inviting patients to read their clinicians’ visit notes may be a meaningful way to engage patients in safety strategies, as urged by experts. The full article, Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes, is open access and available online.
- Of the 22,889 note-readers surveyed, 21% (4,830) of the responding patients reported finding a mistake in their notes.
- 42% of these characterized a mistake as serious.
- Women, older patients, those with more education, and those who reported being in fair or poor health were more likely to report a serious mistake, compared to their counterparts.
“Multiple studies have shown patients and families hold unique knowledge about themselves and their care, and their reports hold strong potential for improving individual and organizational safety,” said Sigall Bell, MD, Associate Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, and lead author of the study. “Most patients who read notes find them to be accurate, reflecting the earnest and thoughtful work of clinicians. Medicine is a practice that relies heavily on communication, known to have vulnerabilities. Where there are breakdowns or misunderstandings, there is a new opportunity to engage patients and address these issues early on.
“Compared to younger and healthier patients, the finding that those older and sicker were twice as likely to report serious mistakes has important implications for improving safety for those with the heaviest burden of illness. We found that 8 in 10 patients who read their visit notes reported feeling ‘very confident’ in their ability to find mistakes in their notes. Most people in the United States are not reading their doctor’s notes, and this lack of review is a missed opportunity to improve safety.”
Among 480 patients who found errors they characterized as “very serious,” mistakes in diagnoses were cited most often (28%), followed by inaccuracies about medical history (24%) and medications (14%). Seven percent reported breakdowns in patient-clinician communication, including activities documented by a clinician that the patient perceived did not happen at the visit (e.g., informed consent or counseling on specific issues). An additional 7% reported physical exam errors, including documentation of parts of the exam they perceived were not done. Six percent reported finding information in their records about other people, and 3% detected errors about sidedness (e.g., “left arm” versus “right arm”).
“Cultural shifts toward transparency, along with nationwide growth of secure electronic patient portals and new federal rules, make it increasingly likely that patients will access their medical records, including visit notes,” said Catherine DesRoches, DrPH, Associate Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, and the senior author of the study. “This study shows us that inviting patients to report on potential mistakes, especially those they believe are most serious, may improve record accuracy, patient experience, and care. Given that patient-reported mistakes were often related to the diagnostic process, patients may also help improve diagnoses when provided with access to notes, and if we develop reporting systems that are responsive and easy to use.”
Researchers conducted this online survey of patients who received care in outpatient settings at Beth Israel Deaconess Medical Center in Boston, University of Washington Medicine in Seattle, and Geisinger in Pennsylvania. Invitations were sent to 136,815 patients, and 29,656 responded to the survey. 22,889 participants were patients who had read at least one clinical note in the past 12 months and answered questions about mistakes.
This work was supported by grants from the Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, the Cambia Health Foundation, and the Peterson Center on Healthcare. Dr. Bell reports funding from the Agency for Healthcare Research and Quality (AHRQ) for separate but related work.
Tom Delbanco, MD, Jan Walker, RN, MBA, and Catherine M. DesRoches, DrPH, at Harvard Medical School and Beth Israel Deaconess Medical Center; Patricia S. Fitzgerald, MSc, and Kendall Harcourt, MPA, at Beth Israel Deaconess Medical Center; Joann G. Elmore, MD, MPH, at David Geffen School of Medicine, UCLA; Alan Fossa, MPH, at University of Michigan, Ann Arbor; Suzanne G. Leveille, PhD, at Harvard Medical School and University of Massachusetts Boston; Thomas H. Payne, MD, at University of Washington School of Medicine; and Rebecca A. Stametz, DEd, MPH, at Steele Institute for Health Innovation, Geisinger.
OpenNotes, based at the Beth Israel Deaconess Medical Center in Boston, a major Harvard Medical School teaching hospital, studies the effects of shared clinical notes on patients, care partners and clinicians, and disseminates its findings. OpenNotes works with collaborators around the country and overseas to foster and evaluate the spread and implementation of shared clinical notes (“open notes”). OpenNotes does not develop software and is not a technology company. It is funded entirely by federal and philanthropic grants and gifts. To learn more, visit www.opennotes.org.
About Beth Israel Deaconess Medical Center
Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School and consistently ranks as a national leader among independent hospitals in National Institutes of Health funding.
BIDMC is in the community with Beth Israel Deaconess Hospital-Milton, Beth Israel Deaconess Hospital-Needham, Beth Israel Deaconess Hospital-Plymouth, Anna Jaques Hospital, Cambridge Health Alliance, Lawrence General Hospital, Signature Healthcare, Beth Israel Deaconess HealthCare, Community Care Alliance and Atrius Health. BIDMC is also clinically affiliated with the Joslin Diabetes Center and Hebrew Rehabilitation Center and is a research partner of Dana-Farber/Harvard Cancer Center and the Jackson Laboratory. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.org.
BIDMC is part of Beth Israel Lahey Health, a new health care system that brings together academic medical centers and teaching hospitals, community and specialty hospitals, more than 4,000 physicians and 35,000 employees in a shared mission to expand access to great care and advance the science and practice of medicine through groundbreaking research and education.