A Comprehensive Guide for Patients and Families Experiencing a Medical Error
- EvaluCare
- May 24
- 7 min read
Updated: 3 days ago
Experiencing a medical error can be overwhelming and distressing. It's crucial to take informed steps to understand what happened, ensure your safety, and seek accountability if necessary. This guide outlines actionable steps to help you navigate such situations.
This blog is focused on collecting as much information as you can from caregivers involved and taking steps to document what is communicated and access tools to get access to documentation in your medical record.
1. Request a Formal Disclosure Conversation
Why it matters: Healthcare providers are ethically and legally obligated to disclose medical errors to patients. A formal disclosure provides clarity on what occurred and should be provided by the attending physician involved in the care. It should ideally include the causes, contributing factors, and any corrective actions taken, and those involved.
How to do it: Ask your healthcare provider or hospital administration to arrange a disclosure meeting. During this conversation, take notes or have a trusted individual accompany you to document the discussion.
2. Engage with the Patient and Family Advocacy Department
Why it matters: Patient advocates serve as liaisons between patients and healthcare providers, helping you navigate the healthcare system, access information, and voice concerns. If an organization doesn't have an advocacy program, reach out to the quality leader, who also can meet the need.
How to do it: Contact the hospital's patient advocacy department to discuss your concerns. They can assist in facilitating communication with medical staff and guide you through the hospital's complaint or grievance process.
Be aware: Patient and Family Advocacy Departments work closely with healthcare providers and hospital patient safety, quality, risk management, legal and hospital executives when errors occur.
3. Speak Directly with the Attending Physician
Why it matters: The attending physician oversees your care and can provide insights into the treatment provided, decisions made, and any complications that arose. At some organizations, it may be the attending physician who has the disclosure conversation. If you had an error disclosed by someone other than the attending physician responsible for the quality of care for the service, also have a conversation with the attending physician.
How to do it: Request a meeting with the attending physician to discuss your concerns. Prepare specific questions and consider having someone accompany you to take notes.
4. Consult with Nursing Staff and Allied Health Professionals
Why it matters: Nurses and allied health professionals (e.g., therapists, technicians) are intimately involved in patient care and may offer valuable perspectives on your treatment and any potential issues. Their experiences of care may be vastly different than the physicians. Other providers on the healthcare team may have highlighted the error.
How to do it: Ask the patient and family advocate to reach out to the nurse manager or relevant department heads to arrange discussions with staff members involved in your care.
5. Document All Interactions and Information
Why it matters: Keeping detailed records ensures you have an accurate account of events, which is essential for understanding the situation and pursuing any necessary actions.
How to do it: Maintain a journal noting dates, times, names of individuals spoken to, and summaries of conversations. Include any symptoms experienced, treatments received, and changes in condition.
6. Request that Everything Communicated is Documented in Your Medical Record
Why it matters: Ensuring that all discussions and events are recorded in your medical record creates an official account that can be referenced later. Not everything that is communicate is reflected in the medical record. Ask and advocate that it is.
How to do it: Politely ask healthcare providers to document your concerns, the information provided, and any agreed-upon next steps in your medical record.
7. Inquire About Open Notes Access
Why it matters: Open Notes is a practice where patients have access to their clinical notes, promoting transparency and patient engagement. Not all parts of the medical record are shared with patients and families. In Open Notes organizations, you will see all provider notes. NCBI+1The Doctors Company+1
How to do it: Ask your healthcare provider if they participate in Open Notes and how you can access the clinical notes about your care. This can help you better understand your care and identify any discrepancies. If you can’t access all notes, just make note of which ones you can’t access
8. Request Submission of a Patient Safety Report
Why it matters: Patient safety reports are internal documents used by healthcare organizations to analyze and improve safety practices. Reporting an incident can prompt a review and potential systemic changes to prevent the same error occurring to another patient.
How to do it: Ask your provider or the patient advocacy department to file a patient safety report regarding your concerns and the error that occurred. While the details of the report may be confidential, its submission indicates that the issue is being formally addressed.
9. Obtain Access to the Patient Portal
Why it matters: If you don’t have access to a patient portal you will need it. It provides timely access to your medical records, test results, and communication with providers, facilitating better understanding and management of your care.
How to do it: Before discharge, request assistance in setting up access to the hospital's patient portal. Regularly review your records for accuracy and completeness.
10. Gather All Medical Records and Related Documents
Why it matters: Comprehensive documentation is essential for understanding your care and is critical if you decide to seek a second opinion or pursue legal action. Errors often result in additional care. Be sure you understand what you need to heal.
How to do it: Request copies of your complete medical records, including test results, imaging, medication lists, and provider notes. Organize these documents chronologically for ease of review.
11. Seek a Second Medical Opinion
Why it matters: A second opinion can provide additional insights into your condition and the care received, potentially identifying errors or alternative treatment options if you need additional treatment.
How to do it: Consult another qualified healthcare provider, preferably one not affiliated with the original institution, to review your case and offer an independent assessment.
12. Limit Discussions on Social Media
Why it matters: Publicly sharing details about your medical concerns can inadvertently affect potential legal proceedings and privacy.
How to do it: Refrain from posting about your situation on social media platforms. Keep discussions private and within appropriate channels.
13. File a Complaint with the Healthcare Organization and/or Relevant Oversight Bodies if Concerns are Ignored
Why it matters: The law requires healthcare organizations to address patient concerns. Additionally, regulatory agencies oversee healthcare providers and institutions, ensuring standards are met and addressing complaints. All organizations must provide patients with access to reporting alternatives.
How to do it: Reach out to your advocacy department or heatlcare provider directly. If needed they can help identify the appropriate agency (e.g., state medical board, hospital accreditation organization) and follow their procedures for filing a complaint. Provide detailed information and any supporting documentation.
14. Ask the Healthcare Provider to Hold Medical Bills
Why it matters: Errors are stressful enough and getting an influx of related bills for care can confound you focus on getting additional care you may need to recover from the medical error
How to do it: Ask the patient and family advocate to hold your bills.
14. About Three Weeks After the Event, Make a Formal Medical Records Request for Your Complete Record
Why it matters: Getting a complete electronic set of your medical records is important to understand care delivered, errors made in the context of not just the encounter but also your condition as a patient
How to do it: Health Information Management departments can process your request. There may be charges for your full record, and paper copies.
15. Consider Engaging EvaluCare for a Medical Care Review
Why it matters: EvaluCare offers expert reviews of medical care to provide insights into medical care and errors.
How to do it: Visit EvaluCare's website to learn more about their services and initiate a review of your medical care.
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Eva, EvaluCare’s AI-powered SaaS, delivers quality review for inpatient care by checking adherence to thousands of evidence-based guidelines and protocols. It identifies care gaps, routes clear actions to the right clinicians, and accelerates improvement cycles, strengthening documentation and coding while reducing HACs, HAIs readmissions, length of stay and more. The result is an ROI, starting in the seven figures even for critical access hospitals. Learn more at evalucare.net or contact info@evalucare.net.
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About the Author
Jason Minor is a healthcare quality and transformation leader with nearly 30 years of continuous improvement experience. A Certified Lean Six Sigma Black Belt, Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, and Certified Utilization Review Professional, he has led thousands of end‑to‑end improvement projects, mentored dozens of quality professionals, and pioneered healthcare SaaS innovations.
As Board Chair of the Vermont Program for Quality in Health Care, Jason has partnered with hospitals, non‑profits, and state agencies to elevate patient safety and care quality statewide. Previously, as Network Vice President of Quality at the UVM Health Network and through the Jeffords Institute for Quality, he guided the redesign of a system‑wide quality framework and led initiatives that achieved a number‑one patient safety ranking among the nation’s top academic medical centers.
In 2020, Jason founded EvaluCare to help organizations shift from episodic improvement to a robust quality assurance approach.
EvaluCare’s Eva platform leverages AI‑powered natural language processing, machine learning, and agentic orchestration to analyze and improve inpatient care and support comprehensive quality, mortality, peer, and utilization reviews.
Jason Minor, EvaluCare Executive Director
Network Director Continuous Systems Improvement Jeffords Institute for Quality UVM Health
Board Chair Vermont Program for Quality in Health Care Inc.,
Vice Chair Northwestern Counseling & Support Services, Inc
Lecturer UVM College of Nursing & Health Sciences in Healthcare Quality
Quality Peer Reviewer Vermont Care Partners: Centers of Excellence
Additional Resources:
Agency for Healthcare Research and Quality (AHRQ): Offers information on patient safety and reporting systems. AHRQ Patient SafetyHealth Vermont+2PSNet+2NCBI+2
The Joint Commission: Provides a platform to report patient safety concerns. Report a Patient Safety ConcernThe Joint Commission+1The Joint Commission+1
OpenNotes: Promotes transparency by giving patients access to their clinical notes. OpenNotesNCBI+2Open Notes+2Revele+2
MedlinePlus: A resource for health information from the National Library of Medicine. MedlinePlus
EvaluCare – Medical Care Review Services
A team of clinical and hospital quality leaders that independently reviews medical care to identify potential errors, negligence, or malpractice. Get a professional, detailed review of your medical records to understand whether you received appropriate care and determine your next steps.
Conclusion
Facing a potential medical error or malpractice situation is challenging, but taking proactive steps can empower you to seek clarity, ensure your safety, and pursue appropriate remedies. Remember, you are not alone, resources and professionals are available to support you through this process.
Learn more at www.EvaluCare.net or email info@EvaluCare.net
