March 2008
Knowing Your Medical History Can Prevent Unnecessary Surgery
Internal Medicine and Subspecialties; Nursing; Radiology; Surgery


Patients who do not know their full medical history are at greater risk to receive unnecessary surgery or medical care. Reports submitted to the Patient Safety Authority show that most at risk are patients who are elderly and may suffer from some form of dementia. In some cases, the patient’s loved one was responsible for knowing their medical history and was unable to provide the necessary information.

Three Real-Life Pennsylvania Cases within Two Weeks

The Patient Safety Authority received three reports of attempted gall bladder removal in patients who had previously had their gallbladders removed within a two-week period. In each case, the patient was misdiagnosed with having gallstones after showing symptoms of the disease and testing positive after having an ultrasound. All three patients received the gallbladder surgery only for surgeons to discover there was no longer a gallbladder in each of the patients.

These cases share several characteristics that suggest potential risk factors for this type of problem:

  • All three patients were of advanced age, with the youngest being over age 80.
  • All three patients were poor historians and could not inform their doctors definitively that they had previously had their gallbladder removed. In one report, the patient suffered from Alzheimers-related dementia, and the other two reports indicate that family members were involved in providing the patient history.
  • In each case, either the patient or a family member expressed uncertainty about a prior gallbladder surgery.
  • All three reports cite an ultrasonogram that read positive for gallstones.
  • In one case, the patient had a history of unrelated prior abdominal surgery that could have explained a visible surgical scar without necessarily alerting the surgeon to a likely prior gallbladder surgery.

The Authority received two additional reports of patients with prior gall bladder removal whose ultrasounds were read positive for gallstones. But these patients helped prevent the unnecessary surgery by speaking up and correcting the misdiagnosis. The patients in these cases were much younger than those in the cases described above and were not poor historians. These reports are accompanied by many others that show medical errors could have been prevented if the patient or family member were able to give a complete medical history.

What You Can Do:
  • Know your medical history and ensure family members know your complete medical history.
  • Write your medical history down if necessary and let family members know where to find the information.

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