A complete and accurate patient history is essential for patient safety. Medical and surgical information is typically reported by the patient using a checklist to indicate medical and surgical history and current medications and supplements. This method has been shown to be generally successful in obtaining an accurate history in most healthcare settings.1,2 However, there are instances when patients may withhold information. Patients may hesitate to disclose information when they fear a procedure may be canceled, when a topic is sensitive,3–5 or when they don’t understand that a particular detail is important to their care.5 Examples of sensitive topics may include pain management, abortion care, weight loss, gender-affirming care, and medical marijuana use.
Recent event reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) included patient safety events that involved patients withholding relevant medical information for fear of a procedure being canceled. Some event reports described patients who underwent a surgical procedure and experienced complications, which necessitated transfer to a higher level of care. After a discussion between the facilities’ patient safety officers and Patient Safety Authority advisors, it was discovered that these patients had a known medical condition but did not disclose this on their medical history form because they were worried that their procedure might be canceled. In these cases, these preexisting conditions would not have necessitated cancellation, but their course of treatment would have been modified to prevent the complication and, in turn, the transfer to a higher level of care. Other event report submissions describe procedure cancellations due to an active infection, which the patient did not initially disclose to avoid the cancellation. Each case involved sensitive topics and procedures, which may have led to patients withholding information.
As medical care, social norms, and laws change, it is important to review the process of collecting medical information to ensure that new medications, treatment modalities, and other factors are considered. Instead of asking patients to indicate pertinent medical and surgical history on a paper or electronic form, it may be helpful to actively discuss patients’ history with them. This will allow for both healthcare providers and patients to better understand the risks involved and how changes may be made to their course of treatment. Additionally, the medical history form could be updated to include a statement explaining that the list of conditions being asked about is to ensure patient safety and may not require a procedure to be canceled. Updating the process of obtaining patient medical and surgical history can ensure collection of more accurate and comprehensive information, enhancing patient safety by adapting to healthcare and societal changes.
Disclosure
The authors declare that they have no relevant or material financial interests.
This article was previously distributed in a September 2, 2024, newsletter of the Patient Safety Authority, available at https://conta.cc/4gd8OOj.
About the Authors
Christine E. Sanchez (chrsanchez@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority. She is responsible for utilizing patient safety data, combined with relevant literature, to develop strategies aimed at improving patient safety in Pennsylvania.
Catherine M. Reynolds is a patient safety advisor with the Patient Safety Authority, working directly with more than 80 healthcare facilities in the Southeast region of Pennsylvania to improve patient safety through consulting, education, and collaboration. She is an accomplished healthcare and patient safety professional, specializing in the analysis of adverse events and facilitywide implementation of patient safety plans.