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!)


About APPLE Allies
APPLE is a volunteer organization at the University of Missouri. It stands for Allies Partnering with Patients for Literacy Education. APPLE's mission is "to assist patients with limited health literacy. APPLE will work to improve health literacy by fostering relationships between Mizzou students with health backgrounds and Columbia patients with limited health literacy. Allies will meet with patients and accompany them to medical appointments if desired. Allies will be available to help patients understand and process information by using plain language, develop questions for the patient’s physicians, and research diagnoses and treatment options or plans. An Ally will work closely with the patient in order to meet as many of the patient’s needs as possible."

3 Responses to Why not put adverse events right in patient charts?

  1. Great story, hopefully these kinds of events can be touchstones for spreading the wisdom that can change a culture for the better.

  2. Pingback: How To Engender A Reporting Culture « Educate the Young

  3. easmith3 says:

    I think this is the best way to look at thing which occur. It is better to let the patient know of a mistake or accident. Again we are only human and the oppourtinity for an incident to occur is significant. I think this a great example of how we should all be.

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