WHAT YOU NEED TO KNOW

By Christine E. Sanchez, MPH & Catherine M. Reynolds, DL, MJ, RN

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.

In some patients, anesthetics can cause a severe, sometimes lethal, reaction known as malignant hyperthermia (MH), with symptoms such as a dangerously high body temperature, rigid muscles or spasms, and a rapid heart rate. It is important to communicate a history of MH to operating room (OR) staff before a surgical procedure, but at one hospital in 2017, the surgeon’s office did not inform Scheduling, Anesthesia, or the OR of the patient’s history of MH.

Fortunately, it was identified immediately preop and the team took appropriate precautions, resulting in no harm to the patient. However the near miss prompted the Preadmission Center clinical leader and the OR operations manager to investigate the

incident to prevent this from happening again, and the clinical risk coordinator referred the issue to the Health Information Technology (Health IT) team and requested an alert to fire when a patient with a history or family history of MH is being planned for surgery. As a result, a multidisciplinary team comprised of Anesthesiology, Preadmission Testing, OR, Health IT, and Risk Management developed new case alerts in the electronic health record for MH incident to prevent this from happening again, and the clinical risk coordinator referred the issue to the Health Information Technology (Health IT) team and requested an alert to fire when a patient with a history or family history of MH is being planned for surgery. As a result, a multidisciplinary team comprised of Anesthesiology, Preadmission Testing, OR, Health IT, and Risk Management developed new case alerts in the electronic health record for MH.