Summary
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. However, there are instances when patients may withhold information. Patients may hesitate to disclose information when they fear a procedure may be cancelled, when a topic is sensitive, or when they don’t understand that a particular detail is important to their care. Examples of sensitive topics may include pain management, abortion care, weight loss, gender-affirming care, and medical marijuana use.
Content
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 cancelled. 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 cancelled. 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.
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