Correcting errors in electronic health records can be trickier to deal with than correcting errors in paper records, according to Georgette Samaritan, senior risk manager and patient safety consultant with Atlanta-based MAG Mutual Insurance Company.
Samaritan, writing an article in Medscape Business of Medicine, noted that unlike errors found in a paper record, correcting an electronic error may completely override the initial error, making it look as if the record never contained a mistake. That, in turn, means that a clinician has no way to show that he or she relied on erroneous data when treating a patient. Samaritan recommends, among other things, that clinicians:
- Work with their EHR vendor to see if and how it allows error correction
- Make sure the EHR has the capability to track such changes
- Don't allow the EHR to override initial data
- Include a narrative in the medical record regarding the error and the correction made
- Flag in the EHR that the record has been amended
"If this sounds like a hassle, it is," she says. "But it's the right thing to do for your patients, and if you should ever be sued for malpractice, your EHR can be your best friend or your worst enemy, depending on how accurately patient records are kept."
EHRs can often reduce errors by use of automation and alerts to complete required fields. However, mistakes do occur due to design issues, such as coding software problems or user input error. EHRs also can increase malpractice risks by use of default settings, "backfiring" of changes and loss of data while transitioning to paper.
To learn more:
- read the article in Medscape Business of Medicine