When Liz Tidyman's elderly parents moved across the country to be closer to their children and grandchildren years ago, they carried their medical records with them in a couple of brown cardboard folders tied with string.
Two days after their arrival, Tidyman's father fell, which had not happened before, and went to a hospital for an evaluation. In the waiting room, Tidyman opened the folder. "Very soon I saw that there were pages and pages of notes that referred to a different person with the same name a person whose medical conditions were much more complicated and numerous than my father's," she said.
Tidyman pulled out sheets with mistaken information and made a mental note to always check records in the future. "That was a wake-up call," she said. Older adults have cause to be careful about what's in their medical records.
Health Information Technology
Although definitive data are not available, the Office of the National Coordinator for Health Information Technology estimates that nearly 1 in 10 people who access records online end up requesting that they are corrected for a variety of reasons.
In the worst-case scenario, an incorrect diagnosis, scan or lab results may have been inserted into a record, raising the possibility of inappropriate medical evaluation or treatment. Este, too, is something that Tidyman's father is soon after moving from Massachusetts to Washington. (Her parents have since passed away.)
When both his new primary care doctor and cardiologist asked about kidney cancer – a condition he did not have – Tidyman reviewed materials from her father's emergency room visit. There, she saw that "renal cell carcinoma" (kidney cancer) was listed instead of "basal cell carcinoma" (skin cancer) – an illness her father had mentioned while describing his medical history.
"It was a transcription error; something we clearly had to fix," Tidyman said. Omissions from medical records allergies that are not noted, lab results that are not recorded, medications that are not listed can be equally devastating.
Susan Sheridan has discovered this nearly 20 years ago after her husband, Pat, had surgery to remove mass in his neck. A hospital pathology report identified synovial cell sarcoma, a type of cancer, but somehow the report did not reach his neurosurgeon. Instead, the surgeon reassured the couple that the tumor was benign.
Six months later, when Pat returned to the hospital in distress, this error of omission was discovered. By then, Pat's untreated cancer had metastasized to his spinal canal. I have died 2½ years later.