Human Error in Electronic Medical Records and the Risk of Malpractice

Electronic health records (EHS) are the digitized version of a patient’s paper charts. EHRs contain information about the patient’s medical history, diagnoses, medications immunization dates, allergies, radiology images and lab test results according to healthit.gov. One of the key features of EHRs is that a record can be created, managed and consulted by health care providers and staff across more than one health care organization, and provide real time information that providers can use in making decisions about their patients’ care. However, these and the many other benefits that electronic health records can provide are really only effective when the information is accurate.

The initial goal of electronic health records was to eliminate doctor scribble and make patient’s medical charts legible for everyone who needed to consult them. EHRs have the potential to make the health care setting safer, but for the moment whether they have or not is unclear.

The HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 contained an incentive to implement electronic health records and penalize those who don’t. For those who do not implement an EHR system their Medicare and Medicaid reimbursement rates will be reduced by one percent each year.

In order to facilitate compliance with the HITECH Act, the Centers for Medicare & Medicaid Services (CMS) established a three-stage implementation program to encourage physicians in private practice and hospitals to implement EHR systems which began in 2011 and will conclude in the third quarter of 2017.

The factor of human error in electronic medical records

In an article on Politico.com, the author writes about an elderly woman who had stabbed herself with a garden fork. An emergency room nurse clicked the “unknown/last five years” tab for the woman’s status as to whether she had a tetanus shot. A doctor took this to mean that she did not need a tetanus shot when in fact she had never received one. The woman ended up dying of tetanus.

In another case which ended up settling for $10 million, a plaintiff maintained that an error in his medical record led to the use of an inappropriate antibiotic that caused him to require dialysis.

In a study conducted by the Louisiana State University School of Medicine, researchers found that less than half of the electronic medical records were complete and free of errors.

The pace of lawsuits related to errors in electronic health records nearly doubled between 2013 and 2014 as the pace of the adoption of EHRs in hospitals and doctor’s offices increased. Errors can range from typos that lead to prescribing the wrong medication to errors that result in patient injury.

Some examples of electronic health records human errors include:

• The use of the “copy and paste” function, which can lead to errors that get multiplied as many times as the inaccurate information is copied.
• Errors in data entry. A person is looking at a paper chart and typing the information into a screen which can lead to errors.
• Accidental or intentional deletion of records
• Unauthorized log-ins and data breaches

To protect yourself and your records, Forbes recommends:

• Requesting a copy of your medical records and reviewing them thoroughly. If you find any errors have them corrected immediately.
• Reviewing your prescriptions. The most common errors involve prescription medication errors. Discuss all of your medications with your doctor and make sure you know why you are taking a drug, how often you should be taking it, proper dosing and what side effects to watch for.
• Looking at your lab work. When you get lab tests, request a copy of the results for your own files.
• Keeping notes of your own. Bring a voice recorder (if you have a smart phone your likely have a voice recorder app) and record conversations with your doctor so that you can replay them.

An article in Healthcare IT News, reviews some of the mix-ups caused by EHR systems that increase medical malpractice risk for doctors. The author draws a distinction between two factors that lead to EHR errors: the first is unsafe technology and the second is unsafe use of the technology. Unsafe technology refers to glitches in the system that are beyond the control of the user. Unsafe use can be traced back to insufficient training to human error.

When they are accurate and complete, EHRs can be a useful tool. While lawsuits because of EHR error are still limited, their use creates the potential for a lot of confusion and errors which could potentially lead to injury.

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