By Physician’s Weekly Blogger, Skeptical Scalpel
My comments are in italics.
Over the course of my 45 or so years in the business, I have noticed many patient charts contain errors. I’ve never stopped to count them, but some investigators recently did. Of 22,889 surveyed patients who read their own records, 4830 (25%) found mistakes. Almost 10% were classified as very serious, 42.3% as serious, and 32.4% as somewhat serious.
Patients were asked to give free text descriptions of mistakes. The most common type of error involved a current or previous diagnosis. Some of the diagnostic errors cited were as follows: a patient with BRCA-1 was labeled as non-BRCA-1; another without lung cancer was said to have the disease; a physical therapy referral was made for the wrong body part.
Other mistakes identified by patients included inaccurate medical histories, errors describing medications or allergies, records listing informed consent or counseling discussions that patients said did not occur, and “errors pertaining to the physical examination, including elements of the examination that, according to the patient, were documented but not done.” I once fired a resident for documenting a physical exam he never performed. The patient was the daughter of a member of the hospital’s board of trustees.
The subjects surveyed were patients at three major US hospital systems. The authors came from five leading academic centers.
The free text comments by the patients were most interesting. For example, “My cardiologist repeatedly says that I ‘deny’ symptoms (such as shortness of breath, etc.) that he never asked me about and that I never denied having.” This is likely caused by the templated review of systems in the electronic medical record. As an aside, I have always felt that the word “denies” is accusatory—implying that we do not believe the patient. “Doctor reported that I did not claim to have pain in my hand. I am a pianist and I went specifically because pain was in my hand.” In addition to this type of error, I often see notes stating such things as “Patient reports feeling better,” and in the next paragraph, “The patient is having more pain.” This may be caused by copying and pasting from the previous visit’s note.
“I have been complaining of difficulty breathing [for over 3 months]. It has been a real and increasing problem for me, but is not mentioned in my notes. In fact, notes saying my breathing is normal are made for each visit.” Again, copying and pasting may be the culprit. Another common issue is the history and physical may say the patient complains of abdominal pain, but the review of systems template, hurriedly checked as negative, says “Denies abdominal pain.”
“A provider not only failed to mention risks and side effects of the injection he wanted to give, but sarcastically derided my concern about long-term risks. ‘Where’d you hear that, the Internet?’” I have seen informed consent discussion documentation that is half a page long and contains passages like “He/she had no questions and agreed to the procedure.” One wonders if all 15 or 20 enumerated risks were actually explained to the patient.
Many patients reported the mistakes to their clinicians and some were dismayed to find that the errors were not corrected. In a few such cases, patients sought care elsewhere.
When you are a patient, take advantage of the opportunity to review your own records for accuracy and make sure errors are corrected. You may not understand everything you read, but do not let that discourage you.
Skeptical Scalpel is a retired surgeon and was a surgical department chair and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last 9 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 3,700,000 page views, and he has over 21,000 followers on Twitter.