Evidence underscores the role patients can play in patient safety when they are granted patient data access.
One in five patients find what they say is a mistake in their own medical records, and two in five patients perceive those errors as serious, according to a group of researchers from Boston, Los Angeles, Pennsylvania, and Seattle. These findings underscore the importance of opening up patient data access and patient-generated error reports.
Patients are in a strong position to detect medical errors and mistakes in the medical record, an issue that afflicts at least half of EHRs, most estimates state. The push for better data transparency and patient data access has sparked a movement toward patient empowerment in the patient safety team.
Specifically, OpenNotes, the philosophy dictating that patients have access to clinical notes through the patient portal, has shown promise to enable patients to detect potential medical errors.
“Patients and families hold unique knowledge about themselves and their care, and their reports have potential for improving individual and organizational safety,” the research team, which included many OpenNotes leaders, explained in JAMA Network Open.
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“They experience aspects of care not seen by practitioners, such as events that transpire between visits or care transitions. Patients and families may also detect breakdowns in care, including some events missed by practitioners, and aggregate patient reports can identify organizational strengths and weaknesses.”
And it’s that patient expertise and adequate patient data access that can lead to detection of medical errors, the researchers said.
The researchers surveyed patients at three OpenNotes healthcare organizations about how often they have reported a medical error and how serious the patient perceived the error to be.
Of the nearly 30,000 patient respondents, 77 percent said they had looked at their clinical notes at least once. Twenty-one percent said they had found what they said was a mistake in their medical records, while 32 percent said the mistake was somewhat serious and 9.9 percent said the mistake was very serious.
Most of the reports (58.9 percent) of the very serious errors were associated with the diagnostic process, meaning documenting the medical history, conducting the physical examination, noting tests, making referrals, or documenting other patient-provider communication.
Looking more generally, just about a quarter of all EHR mistakes were related to diagnosis (27 percent) or an inaccurate medical history (23.9 percent). Fourteen percent related to a wrong allergy or medication list, while 6.5 percent of patient reports were about notes written about the wrong patient.
What’s more, it is often more engaged patients who report perceived medical record errors. Female patients, individuals with higher educational attainment, older adults, sicker patients, and those who had looked at more than one clinician note were more likely to report a serious error than their counter parts.
These findings underscore the key role patients can play in the patient safety process. Although the study did not look at whether these patient-reported medical record errors were validated and resulted in medical record changes, the data underscores that patients are able to detect potential errors.
Of course, the process of patients reporting errors in their clinical notes and medical records is not perfect. As noted above, there may be discrepancies between patients and providers about whether something is indeed a medical error.
However, looking at the patient-reported errors that patients have perceived as most serious or most important may be a good place to start. After all, most of the notes patients said were very serious were clinically relevant, the researchers said.
And even when providers do not think a patient-reported medical record error is serious, addressing the concern with the patient can result in improved patient experience and better rapport.
Conversely, looking at medical record errors that patients do not perceive as serious — but that providers do — can help target patient education efforts. If a patient does not think a dosage mistake on a medication list is serious, for example, the provider may be prompted to review the importance of medication management with that patient.
These findings further underscore the outsized role patients have begun to play in their own medical care, the researchers said. Since the push for more value-based care came to define the healthcare industry, medical professionals have asserted that an engaged patient is often a healthier patient.
This logic can apply to patient safety, as patients empowered with data access and open notes are proving to be better equipped to take part in safety checks.
“As safety leaders seek ways to engage patients and families actively in the diagnostic process, sharing clinical notes may be a scalable first step, especially because patient-reported errors related to diagnosis, medical history, physical examination, and tests and results were among the most common patient-reported errors in this study,” the researchers concluded.
Source: Patient Engagementhit