Why not put adverse events right in patient charts?

I’m a second year medical student at the University of Missouri, and I’m currently working at an internal medicine practice in St Louis. I’d like to share a recent patient safety story with you.

The patient was an elderly gentleman who had been a long time patient of the doc I’m working with. He had a heart attack a few years ago and has been seeing a cardiologist since then. He recently began experiencing chest pain on exertion, so he went to the cardiologist for an angiogram and possibly angioplasty. He needed two stents.

He had an appointment with us about a week after his angioplasty, and I reviewed the cardiologist’s report before interviewing him. After reading a summary of his blocked arteries and location of the stents, I was shocked (in a good way!) to see this addition at the end: “Adverse event–catheter pierced a small coronary artery. The patient was stabilized and appropriate treatment was administered. The patient remained overnight for observation. We will follow-up in clinic in three days.”

I asked the doc I was working with what he thought of this report. “Well, there’s no reason to hide it if something went not according to plan. People generally like it if you’re honest with them, treat them fairly, and tell them about how you’ll avoid this in the future.” The patient wasn’t angry; he didn’t file a lawsuit; he still uses the same cardiologist.

Next, I went in to see the patient. I asked him about his heart and how his angioplasty went. He smiled and said, “Oh, it was fine. I have two new stents. There was a minor mishap, but I’m OK now.”

Sure is nice to see the principles I learned at Telluride in action!

-Kristin Morrison, University of Missouri

(APPLE Allies, the “author” of this post, is a nonprofit organization I started. We’re working to improve health literacy in mid-MO. Check out our blog!)

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