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Serious Medical Errors Found in Doctor Visit Notes

Medical errors are estimated to be the third leading cause of death in the United States, behind only heart disease and cancer.  According to a new study, many serious medical mistakes are made as early as in the notes taken by physicians.

The study (“Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes”), published this month in the Journal of the American Medical Association, found that 20% of patients who reviewed their doctors’ notes following an ambulatory care visit uncovered an error in those records.  Ambulatory care generally means a same-day medical care procedure, including surgery.

Very Serious Medical Errors Uncovered

And over 40% of the patients who discovered medical errors in their doctors’ notes described those errors as “serious.” Another 10 percent said they were “very serious.”

The research involved nearly 23,000 patients in three health systems.  These health systems had been sharing medical notes with their patients via online portals for seven years.

The patients read at least one note in the previous 12 months. They were asked four questions in the online survey, including:

·         Have you ever found anything in your visit notes (not counting typos) that you thought was a mistake?

·         How important was the most serious mistake you found?

About one out every five (21.1%) of the patients reported finding a mistake.

So what types of medical errors did they find in their medical records?

Misdiagnoses Included in Patient Visit Records

The most common medical error deemed “very serious” involved a doctor’s diagnosis.  More than one quarter of the very serious electronic health record errors reported were a diagnostic mistake, including:

·         Wrong diagnosis – medical conditions recorded but patients said they did not have

·         Omitted diagnoses – those the patients felt were important but were not included in their notes

·         Delayed diagnoses – problems during the diagnostic process

Incorrect test results also were found in patient charts.

The second most common type of very serious medical error found by the patients involved their medical histories.  For example, some patients reported that symptoms they previously described to doctors were not included in the visit records.

Mistakes with medications also represented a leading error.  One patient found the wrong medication dosage – by a multiple of 10 – in a doctor’s note used by a referring physician.

Miscommunication or poor communications by physicians was another source for medical errors.  And poor communications often compounded the original mistake as well, as some surveyed patients relayed their frustrations when trying to correct the errors only to be ignored by medical professionals.

The authors of this research are proponents of open medical record rights for patients, and one of their conclusions was that more patients should be allowed to review their doctor visit notes.

But another lesson learned here is how early in the care giving process serious mistakes can be made – and overlooked.

If you were seriously hurt or had a loved one die during medical treatment and you have reason to believe and error in care was made, speak with a medical malpractice lawyer, who can determine when the mistake was made and who is responsible.

The choice of a lawyer is an important decision that should not be based solely on advertisements.

Authored by Gray, Ritter & Graham, P.C., posted in Blog June 22, 2020