A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers

Abstract

Objective The study sought to test a patient and family online reporting system for perceived ambulatory visit note inaccuracies. Materials and Methods We implemented a patient and family electronic reporting system at 3 U.S. healthcare centers: a northeast urban academic adult medical center (AD), a northeast urban academic pediatric medical center (PED), and a southeast nonprofit hospital network (NET). Patients and families reported potential documentation inaccuracies after reading primary care and subspecialty visit notes. Results were characterized using descriptive statistics and coded for clinical relevance. Results We received 1440 patient and family reports (780 AD, 402 PED, and 258 NET), and 27% of the reports identified a potential inaccuracy (25% AD, 35% PED, 28% NET). Among these, patients and families indicated that the potential inaccuracy was important or very important in 58% of reports (55% AD, 55% PED, 71% NET). The most common types of potential inaccuracies included description of symptoms (21%), past medical problems (21%), medications (18%), and important information that was missing (15%). Most patient- and family-reported inaccuracies resulted in a change to care or to the medical record (55% AD, 67% PED, data not available at NET). Discussion About one-quarter of patients and families using an online reporting system identified potential documentation inaccuracies in visit notes and more than half were considered important by patients and clinicians, underscoring the potential role of patients and families as ambulatory safety partners. Conclusions Partnering with patients and families to obtain reports on inaccuracies in visit notes may contribute to safer care. Mechanisms to encourage greater use of patient and family reporting systems are needed.

Views, Use, and Experiences of Web-Based Access to Pediatric Electronic Health Records for Children, Adolescents, and Parents: Scoping Review

“…In total, 12% (2/16) of the studies focused on the general population [20,21]. Observational studies focused on adoption and use over time, demographic data, and frequently used functions of patient portals [26][27][28][29][30][31], whereas survey studies explored satisfaction with reading the records [23,32,33], literacy [23,32], intervention effects [33], attitudes toward web-based patient portals [21,34], and barriers to adoption [34]. The studies included adolescents aged between 12 and 20 years, and 12% (2/16) of the studies included patients aged ≥18 years [21,32].…”

Attitudes, experiences, and safety behaviours of adolescents and young adults who read visit notes: Opportunities to engage patients early in their care

“…Because we anticipated that the overall number of AYA identifying a serious mistake would be small (based on the literature and the population size), we did not apply statistical testing to compare results to adults and instead report experiences with note accuracy and reporting errors descriptively. 21,22…”

Characteristics of Critical Incident Reporting Systems in Primary Care: An International Survey

“…30,31 Furthermore, patients can also provide rich descriptions 32,33 and a unique perspective on patient safety. 34,35 Patients may also notice issues concerning the transition of care, 7 which is especially valuable for primary care providers trying to ensure continuity of care. European guidelines write, "all staff in healthcare organizations (...) should be able to report patient safety incidents" and encourage reporting by patients and families.…”