Table 4.

Recommendations for overcoming barriers to speaking up by patients and families who feel less comfortable reporting serious mistakes

Theme	n a	Suggestions	Examples
Instructions for how to report and whom to report to	311/476 (65%)	Online method “Neutral party” or someone other than the physician to receive reports An anonymous or confidential method Prompt responses and respect for patient time	“Make it easy to quickly do online…”   “To make a phone call during the day when my doctor is available or the office is open is very challenging. Being able to communicate by e-mail would be very helpful.”   “A confidential discussion with another medical provider…”   “Who would be the best person to tell? Doctors are very busy and if we were to call the office it is unlikely to be done.”   “It would take 4 phone calls to fix, there is no easy way to get anything done over there. It involves phone call after phone call to actually get your point across.”
Cultural change to encourage reporting	114/476 (24%)	Clinician encouragement to report Meaningful responses Assurance against retribution Comfort level with the provider	“Knowing there would be no retribution…with my child’s care.”   “Ease of reporting and reinforcing just working together as a team for accuracy.”   “Knowing if I pointed out the mistakes they would be corrected. Not with an addendum but literally corrected.”   “…Make sure [the] provider won’t get in trouble.”   “Feeling like providers want to hear from parents.”
Proposed innovations for reporting EHR mistakes	79/476 (17%)	Patient and family contributions to notes or “self- notes” Patient and family edits or suggested corrections in the note Alternatives to addenda Reporting templates, normalizing patient feedback, and making feedback language easier for patients	“…if patients could add their own notes, which could include things like points the patient forgot to make in the appointment.”   “Having a checkbox after each note on [the patient portal] that would allow the patient to 1) document that they’d seen the note, and 2) verify that their personal history, family history, and current medical issue and/or reason for visit were accurately noted.”   “Notes [could] be thought of as ‘drafts’ pending patient review.”   “It would help to have some templates online so that I could choose how [to] write about the mistake. I don’t want to offend my doctor and I’m afraid to use [the] wrong words.”   “Make the note clickable and possible to type a correction into it. Then the correction could go to the doctor and she could look at it and click “accept” or “reject,” and she could either delete her own mistake or keep alongside my correction (maybe in another color font).”
Seriousness of perceived mistake	32/476 (7%)	Whether the mistake would affect their health The urgency of reporting mistake	“I’m not sure I would call unless it affected my immediate health.”   “If there were serious consequences, such as [a] recommendation for a condition I don’t have.”
Education on medical concepts, errors, and importance of reporting	20/476 (4%)	Guidance on how to identify errors Understanding why it is important to have accurate notes Reducing jargon in the notes	“I don’t know the consequence of having the note corrected/not corrected.”   “I am not sure why Open Notes is important for me to keep accurate, so an explanation of that would help me report a serious mistake.”   “The notes are filled with acronyms, making it hard to fully understand the doctor’s degree of concern about the issue that included the mistake.”
Access to notes	12/476 (3%)	Having access to all provider notes Sharing notes in a timely manner after the visit	“Having all providers’ notes be eligible for feedback.”   “Immediate access to [the] note while the visit [is] still fresh in my memory.”

^a476 patient comments included a total of 568 recommendations.