Every institution strives to improve medical outcomes. While there are many paths to improved patient care—and thus better and more consistent medical outcomes—thorough and accurate information is critical to uncovering problem areas and improving processes to better protect and care for patients.
The Problem of Medical Record Accuracy
Recent analysis indicates that such information is lacking. In fact, a recent study published in the Journal of Patient Safety indicates that the problem goes far beyond a lack of information to optimize medical outcomes. In “A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care,” John T. James, PhD, concludes that the content and structure of medical records is so lacking that we do not even have accurate data regarding the number of patients who die or suffer other preventable harm in hospitals.
Many reviews rely on non-physician professionals using the Global Trigger Tool to flag specific evidence in medical records suggesting that an adverse event may have harmed a patient. Then, those flagged records are reviewed by a physician to determine whether such an adverse event actually occurred and to determine the severity of patient harm. However, manual review of all records is not viable; a large-scale review depends on the ability to automate the initial screening.
The conclusions James reached, based on the results of four studies published between 2008 and 2011, provide strong incentive to continue and redouble efforts to improve patient outcomes. Previous estimates of deaths due to medical errors, based on a 1984 study, put the number at about 98,000 annually. While that number came as a shock to many Americans, James’s review of these four recent studies puts the lower limit of deaths per year associated with preventable harm in hospitals at 210,000. However, because of limitations on the tool’s search capability and the incompleteness of medical records, it was estimated that the true number could actually be in excess of 400,000 premature deaths per year.
Reducing Medical Record Errors
Obviously, identifying the sources of error and improving processes to improve outcomes and cut back on the number of patient adverse events in a particular hospital and throughout the health care industry depends on thorough and accurate information about patients, cases and the care they received. Unfortunately, a great deal of information that could have been employed in improving outcomes has already been lost. But, this analysis highlights the need for better systems moving forward. Ensuring that medical records are complete, accurate, use consistent language and are easily accessible and searchable will both improve outcomes directly and provide researchers and administrators alike with the data they need to introduce far-reaching improvements.
Better medical outcomes benefit patients, families, clinicians, administrators, institutions and society as a whole. Creating a stronger record through template-based, searchable medical reporting is one important step toward such improvements.
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