A study published on JAMA Network on June 9, 2020 entitled “Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes” stated:
“Errors in electronic health records (EHRs) are common. At least half of EHRs may contain an error, many related to medications. Overburdened practitioners may import inaccurate medication lists, propagate other erroneous information electronically by copying and pasting older parts of the record, or enter erroneous examination findings. EHRs may also lack critical information (errors of omission) because of limited interoperability among health care sites. Among primary care physicians sharing notes with patients, 26% anticipated that patients would find nontrivial errors. Despite these known problems, systems for checking the accuracy of notes are almost nonexistent. As practitioners integrate EHR data into decision-making, such errors could therefore lead to medication errors, wasteful duplication, unnecessary or incorrect treatment, and delayed diagnoses.”
With regard to medication errors, study participants described prescription medications that appeared active but that the patient was no longer taking, new prescription medications that the patient was taking but that were missing, and wrong dosages. Occasionally, patients reported finding medication not intended for them. There were also many reported errors related to medication allergies, including omission of severe or anaphylactic allergic reactions. Some patients detected discrepancies in medication documentation within the note, with dosages correct in one place but incorrect in another.
With regard to medical testing reports, study participants identified that some practitioners reported the wrong test result in the note and others who were not aware that more recent results or reports existed.
With regard to other errors reported by study participants, 14.9% most commonly reflected patients’ perception of something important that was missing from the note (such as active health issues, delivery of vaccines, or recent test results), errors stemming from copy and paste of prior electronic notes, and billing mistakes, such as erroneous codes that implied conditions the patient reportedly did not have. A few patients mentioned errors related to mental health or substance abuse. Several patients reported errors attributable to EHR glitches, such as missing medications after EHR vendor changes, attribution of all tests or vaccination dates to the patient’s birthdate, or a single date for all treatments or operations that reflected the patient’s date of transfer to the organization.
The study’s authors stated: “Reports from more than 22 000 patients who read their practitioners’ notes at 3 US health care centers suggest that patients may play an important role in identifying errors in their records. More than 1 in 5 patients perceived mistakes in their notes, judging more than 40% of them as serious … Older patients and those with poorer health—patients for whom consequences of errors may be most profound—were approximately twice as likely as younger and healthier patients to identify errors they considered serious, suggesting that note sharing may have particularly important safety implications for those with a heavier burden of illness. In addition, we received reports of mistakes that patients perceived as very serious, suggesting that a feedback mechanism for such findings may be useful for engaging patients in safety.”
“Patient-reported mistakes may help prevent medication errors, diagnostic and treatment delay, and duplicated diagnostic tests and procedures, which occur for approximately 25% to 30% of seriously ill patients.”
“Experts estimate that 12 million Americans experience diagnostic error annually, and diagnostic errors represent the most frequent category of paid malpractice claims. Patients who read notes can help ensure that the physician correctly heard and recorded the patient’s symptoms and may also identify mistakes associated with tests and results—known vulnerabilities in some practitioner evaluations.”
If you or a loved one suffered serious injuries (or worse) due to possible medical malpractice involving electronic health records (EHRs) in the United States, you should promptly seek the advice of a medical malpractice attorney in your state who may investigate your medical malpractice claim for you and file a medical malpractice case on your behalf, if appropriate.
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