As many Houston area residents may have observed, the world of health records has moved into the digital age. Most doctors now use electronic health records (EHRs) instead of hand recording. Although this can be more convenient, any errors can have severe consequences, including wrongful death, for patients.
Just years ago, less than 20% of doctors used electronic health records. Adoption has since grown dramatically, with the large majority of doctors now relying on EHR systems. Electronic health records offer a number of advantages to both patients and doctors. Doctors can have quick and easy access to a patient’s health history, medications, and lab results, which often makes patient records more accurate and can allow for better patient care.
How EHR Errors Happen
However, an inaccurate electronic health record can be detrimental to a patient, and mistakes are easy to make. There can be unintended typos and deletions. A drop-down menu can be misinterpreted. Using templates to auto-populate data can also cause errors. And sometimes scribes who are not properly trained on how to use electronic health records make errors that carry through to a patient’s chart.
Patients have suffered many injuries because of inaccurate EHRs. Patients have been given inaccurate medication doses, undergone unnecessary surgeries, and not received proper care because of missing information. In one widely cited example, a doctor misinterpreted a patient’s electronic health record entry reading “unknown/last five years” for a tetanus shot to mean that she did not need one. The patient later died of tetanus after it turned out she had never actually received the vaccination.
When an EHR Error Becomes Medical Malpractice
An EHR error rises to the level of malpractice when a provider’s misuse or misreading of the record falls below the accepted standard of care and that failure causes harm. This can include a doctor who does not verify a critical detail like an allergy or immunization history before proceeding with treatment, or a provider who relies on an auto-populated field without confirming it reflects the patient’s actual condition.
A person who believes they have suffered an unexpected injury due to an inaccurate electronic health record may want to speak with a legal professional experienced in medical malpractice. Compensation may be available for medical expenses, pain and suffering, and other damages tied to the harm caused.
Protecting Yourself as a Patient
Patients can help reduce the risk of EHR-related errors by reviewing their own after-visit summaries and requesting corrections to anything that looks inaccurate, particularly allergy lists, medication histories, and immunization records. If you believe an EHR error contributed to a serious injury, contact Davis & Davis for a free consultation with our experienced legal team.
Source: mdnews.com, “Inaccurate EHRs can have severe consequences for patients and physicians,” Cliff Robertson, April 28, 2016
Frequently Asked Questions About Electronic Health Record Errors
Can I request corrections to my own electronic health record?
Yes. Patients generally have the right to request corrections to inaccurate information in their medical records, and reviewing after-visit summaries is a good way to catch errors early.
Is a typo in my medical record automatically malpractice?
Not on its own. Malpractice requires showing that a provider’s error fell below the accepted standard of care and directly caused harm, not simply that a mistake existed in the record.
What kinds of EHR errors most commonly lead to patient harm?
Errors involving allergy information, immunization history, and medication dosing tend to carry the highest risk of serious harm, since they directly affect treatment decisions.
Who can be held responsible for an EHR-related injury?
Depending on the facts, the treating provider, the hospital or clinic, or in some cases a scribe or staff member who entered the data incorrectly may bear responsibility.
What should I do if I believe an EHR error harmed me or a family member?
Request your complete medical records, including the audit trail if possible, and speak with a medical malpractice attorney to evaluate whether the error fell below the standard of care.
