More than one in five patients perceived mistakes in their notes, judging more than 40% of them as serious. Such is the conclusion of a study published in the June 9, 2020 issue of JAMA.
With the proliferation of electronic health records (EHRs) and the requirement to provide patient access to health information through portals, this mind-blowing article reviewed a study of patient-reported errors. The study revealed that, of the 4,830 patients surveyed, 21% reported a perceived mistake; of those mistakes, 42.3% were considered by the patient to be serious. Of the errors, 32.4% believed them to be somewhat serious, and 9.9% considered them very serious.
The classification of very serious errors included specific errors in current or past diagnoses, inaccurate medical history, medication or allergy mistakes, erroneous reporting of tests, procedures or results. Of the very serious errors, almost 60% of patients perceived at least one mistake potentially associated with the diagnostic process (e.g., history, physical exam, tests, referral and communication). About 14% of respondents reported documented elements of the physical examination that were not done, and documented items such as informed consent and counseling which were not done. A relatively small number of patients reported reading notes on the wrong patient and errors in laterality of reported information (left vs. right).
The researchers reported that at least half of EHRs may contain an error, mostly related to medications, and that 26% of PCPs anticipated that patients would find errors. However, “systems for checking the accuracy of notes are almost nonexistent.” The authors believe that creating a system for routine review of notes by patients could contribute to EHR accuracy and also more fully engage the patient in his or her health care. They believe that sharing patient notes could be a “scalable first step” especially since EHR transparency is sure to increase patient access. Of course, this means that providers will need a systematic mechanism for responding to patient-reported errors.
It is prudent to keep in mind that patients have the right under the Health Insurance Portability & Accountability Act (HIPAA) to request an amendment of their health information, and that Covered Entities (meaning providers) are required to review and respond to those requests to amend or deny amendment to the record, as stated in their Notice of Privacy Practices (NPP). It’s doubtful that patients or providers fully read or recall what is contained in the NPP, or have a mechanism to carry out their responsibilities, but they need to.
Coleman Consulting Group can help your healthcare business establish the proper policies, procedures and processes to successfully harness an important stakeholder’s help in improving the accuracy of your patient records.