Risk Management

Documentation Errors Related to Electronic Health Records

Ryan Bucsi Senior Litigation Analyst

Allegation

No allegations were made as these scenarios did not result in claims. 

Disposition

Practice revised its EHR policy to prevent a recurrence of these errors.

Case Summary 1

A technician copied a patient’s medication list from the paper chart to the electronic health record (EHR). Unfortunately, the technician referenced the wrong chart so the entire list of medications was incorrect. When the error was discovered, the healthy young patient became upset that another patient’s medication list had been entered into his medical record. Despite receiving a phone call and letter of apology from the administrator, the patient lost confidence in the practice and changed providers.

The group then revised its policy on medication entries to require a clinical manager to oversee and sign off on all electronic exam entries by technicians. Any errors subsequently found during audits are brought to the attention of the clinical manager and the technician at fault.

Case Summary 2

The patient’s ophthalmologist was out of the office when a prescription refill request came in. An administrative assistant at the group sent the refill request to a mail order pharmacy without first getting physician approval. Unfortunately, the prescription dosage had been entered into the EHR incorrectly so the refill request was for 0.25% Timolol instead of 0.5% Timolol as the ophthalmologist had prescribed.

When the patient received the refill, she noticed the medication bottle had a blue cap instead of the yellow cap she was used to. She called the ophthalmologist to find out why the cap color had changed, which brought the medication error to the group’s attention.

No harm was done to the patient and she was reimbursed for the cost of the medication. The administrative assistant, a longtime employee of the practice, was given a written warning for breach of the group’s policy, which required physician sign off on all refill requests.

Case Summary 3

An ophthalmologist ordered Durezol for a patient’s iritis and entered the medication into the free text area of the EHR instead of using the medication module. The scribe then sent a prescription request for Dorzolamide to the pharmacy. At a scheduled follow-up visit two days later, the technician also failed to add the prescription to the electronic medication module and copied the ophthalmologist’s order from the previous visit again into the free text area of the chart for the patient’s medications.

Three days after the follow-up appointment, the patient went to the emergency room complaining of increasing pain. The iritis had indeed worsened, and it was in the emergency room that the medication error was finally discovered. The patient chose not to return to the group practice after learning of the error.

A warning was issued to the ophthalmologist, scribe, and technician. The ophthalmologist was credentialed with a hospital system that required use of a different electronic prescribing system from the group’s EHR. To the ophthalmologist, entering the medication in the group’s EHR as well as the hospital’s system seemed to be an unnecessary duplication of effort. Had she done so, however, the discrepancy most likely would have been caught and the patient would not have ended up in the emergency room.

Risk Management Principles

Electronic health records promise faster and more consistent data entry with the goal of improving patient care and safety. Redundancies are built into the system to provide opportunities to double check entries and catch discrepancies before costly mistakes are made. Still, errors do occur and inaccuracies in EHR documentation can have negative consequences for the physician-patient relationship. None of the scenarios discussed here resulted in a professional liability claim or significant harm to the patient, yet two patients chose not to return to the practice and terminated their care with the ophthalmologist.

The use of electronic health records over paper records can be a double-edged sword when claims do arise. They can either be used by the defense to support the physician’s care or by the plaintiff to show a clear and undisputable record of an error.