Patients reveal adverse events in the hospital that are not documented in the medical records
Research Activities, January 2009, No. 341
Hospitalized patients report many adverse events-some serious and preventable-that are not documented in the medical record, reveals a new study. A team of researchers randomly surveyed adults who were hospitalized in 2003 in Massachusetts hospitals about their experience of adverse events during hospitalization. The team also examined adverse events documented in the patients' medical records. They looked at 18 types of events ranging from hospital-acquired infections to surgical complications and adverse drug events.
Among 998 study patients, 23 percent mentioned at least 1 adverse event during their interview, but only 11 percent had an adverse event based on medical record review. Thus, the patients revealed twice the number of adverse events as the medical records did. Agreement between medical records and interviews was somewhat better for life-threatening or serious events. Medical record review identified 11 serious preventable events (1.1 percent of patients). Interviews identified an additional 21 serious and preventable events that were not documented in the medical records, including 12 postdischarge events and 9 postdischarge events in which symptoms occurred after the patient left the hospital.
The authors conclude that postdischarge patient surveys and medical record review are complementary ways to detect adverse hospital events that jeopardize patient safety. The study was supported by the Agency for Healthcare Research and Quality (HS11928). See "Comparing patient-reported hospital adverse events with medical record review: Do patients know something that hospitals do not?" by Joel S. Weissman, Ph.D., Eric C. Schneider, M.D., M.Sc., Saul N. Weingart, M.D., Ph.D., and others, in the July 2008 Annals of Internal Medicine 149(2), pp. 100-108.