Legal and Safety Issues on Electronic Health Records Journal Articles Review

Health care in the United States has experienced a remarkable transition from newspaper to electronic health tape (EHR) systems during the by decade. Thanks in large measure to goals fix by the Federal Health IT Strategic Program and fiscal incentives provided through the ARRA/HITECH act in 2009, more than 75% of physician practices and 92% of eligible hospitals have received incentives to prefer certified EHR technologies through 2014.^one

This transformation has been the subject field of intense scrutiny to determine if EHRs have achieved the original expectations to improve the quality, condom, and efficiency of health care. A series of 4 comprehensive systematic reviews during this time frame have concluded that wellness information technology (health Information technology) has improved in each of these dimensions,^{2–half dozen} and in that location is likewise evidence that the number of malpractice suits has decreased in relation to the implementation of EHRs.⁷ These findings, however, remain controversial; many organizations accept been dissatisfied with their systems, and in that location is widespread agreement that the full potential of this technology has non withal been realized. A written report sponsored by the American Medical Association also cited current EHR applied science as a major source of dissatisfaction among providers.⁸ A host of problems look resolution, including express interoperability, challenging user interfaces, and software design that can degrade efficient clinician workflow and seems to have been optimized for administrative priorities more for quality medical care.^9–11

Of item concern are the examples of unintended consequences of health IT that backbite from the safety of health care or from the use of health It itself. These concerns derive from case reports,¹² claims databases,¹³ reports through patient safety organizations,^14,15 electronic surveillance (event triggers),¹⁶ and adverse and watch consequence reports to The Joint Commission^17,18 and the Veterans Health Administration.^nineteen To address these bug volition require identifying the specific types and characteristics of events that backbite from safety and targeted efforts to address each i.

The goal of this project was to obtain additional data on these health It–related bug, using a mixed methods (qualitative and quantitative) analysis of EHR-related impairment in cases submitted to a large database of malpractice suits and claims. In particular, nosotros sought to place specific error types or trends that would be acquiescent to system- or pedagogy-focused solutions and the overall value of using medical liability claims databases for this purpose.

METHODS

A retrospective, accomplice study of claims in the CRICO Comparative Criterion System (CBS)^twenty was conducted for cases coded during the menses January one, 2012, through December 31, 2014. The CBS is a national database of medical malpractice claims from both commercial and captive insurance companies, reflecting both hospital and clinician take a chance in bookish and customs environments and beyond all care settings. The database contains more than than 300,000 cases from more 500 hospitals and 165,000 physicians. Cases selected for this analysis were both open up and airtight malpractice claims and suits, all filed with regard to injuries incurred during the provision of health intendance services from 2008 through 2014, which also were coded as having one or more EHR identifiers as a contributing factor in the instance. We ultimately analyzed 248 cases. Of these, 147 were derived from cases coded during the catamenia Jan 1, 2012, to December 31, 2012, using a preliminary set of codes relevant to information science issues using electronic medical records.¹³ These codes were reviewed and refined to the current set of 15 proprietary sociotechnical category codes, which were practical to all subsequent cases coded during the period January 1, 2013, to December 31, 2014, from which an additional 101 cases were identified. The original set of 147 cases was so recoded using the newer taxonomy.

Quantitative and Qualitative Analysis

Each merits in the CBS has been previously analyzed by a clinical coding specialist using CRICO's proprietary coding taxonomy. Relevant factors in each instance were identified based on a consummate review of the medical and legal case file including summaries, medical record data, depositions, and legal proceedings. Coding is typically performed by a single coder subsequently all-encompassing training and is based on extensive guidelines developed to standardize the methodology. To ensure the consistent application of the taxonomy, CRICO holds biweekly calls amidst all coders, provides 1.five days of on-site preparation annually, and audits approximately 15% of all cases. Cases were assigned the following codes:

• ▪ Major allegation (case type; medication related, diagnostic, surgical, obstetrics, etc)
• ▪ Setting (inpatient, outpatient, emergency department)
• ▪ Clinical service (medicine [internal medicine, gastroenterology, cardiology, etc], emergency department, radiology, etc)
• ▪ Severity of the clinical outcome, measured by the National Association of Insurance Commissioner's damage scale:
• Loftier: death, permanent grave, permanent major, or permanent significant harm.
• Medium: permanent minor, temporary major, or temporary modest harm.
• Low: temporary insignificant harm, emotional harm only, or legal issue but.
• ▪ EHR-related factors: Among the 200+ contributing factors coded for each case, we studied the 15 EHR-related contributing gene codes in CRICO's proprietary Coding Taxonomy. The EHR-related codes distinguish 2 big categories that identify system- and user-related problems that contributed to events resulting in a medical malpractice claim:
• ▪ System issues include the clinical systems and processes of which the EHR is an expected/integral part and include bug related to availability of data, routing bug, and problems related to alerts and alarms. System-related bug as well include technical bug involving hardware or software, such as security, and design features, such as autopopulating.
• ▪ User-related issues include incorrect or missing information and include such issues as alarm fatigue, re-create/paste, various workarounds, and user-related difficulties working in the EHR, including accessing data in hybrid tape systems or new installations.

Each case that included one or more of the EHR-related contributing factor codes was reexamined for the purposes of this study by two dissimilar, independent reviewers to ensure that a example was advisable for inclusion. Of note, this study focuses simply on cases with one or more specific EHR-related bug (i.e., specifically involving the patient'due south chart) and not broader issues that involve health It such as telemedicine, or electronic devices that interface with the EHR.

Proportions of interest were compared using χ² tests.

RESULTS

In total, 280 of the cases in the CBS database coded over the preceding menstruation of 2 years were identified as having 1 or more contributing factors relating to Hit. Out of these 280 cases, a subset of 248 cases, those specifically associated with EHR-related factors, are reported here. The 32 cases (of the 280) excluded from this report included broader Striking events not related to the EHR. A qualitative summary of the first 147 cases has been previously published.¹³ The 101 cases identified virtually recently (January 1, 2013 through December 31st, 2014) represented just nether 1% of the 12,012 cases coded during that menstruum.

Setting and Responsible Service (Table 1, Fig. 1). Nearly cases derived from the ambulatory care setting [146 ambulatory cases vs 102 from inpatient (77 cases) and ED (25 cases) combined]. There were no cases from extended care facilities. Convalescent errors outnumbered errors from inpatient care and the ED for every major service except for Nursing, where inpatient errors predominated. The service with the most claims was Medicine, followed by Surgery, Nursing, and Obstetrics\Gynecology, and Radiology.

Table one:

EHR-Related Events in Medical Malpractice Claims

Effigy 1:

Distribution of Coded Cases by the Setting of Intendance.

EHR-Related Contributing Factors (Table 2). The current CRICO analytical framework recognizes 2 chief categories of contributing factors: System-related bug and User-related problems. Factors from both of these categories contributed to EHR-related factors, 63% of cases involved user-related issues and 58% involved engineering science related problems; in many cases, more than than ane contributing factor was identified. Representative example examples from each of the various factors are presented in Appendix A.

TABLE 2:

EHR-Related Etiologies Across Settings

System-related issues included a wide range of cases that involved technology and software design issues that adversely afflicted patient outcomes:

• ▪ A main care provider could non access the patient's radiology studies at the time of a patient'southward visit; the newspaper results were filed without the MD seeing these. The patient experienced delayed diagnosis of lung cancer.
• ▪ Reminiscent of a recently-publicized case involving a patient with Ebola infection,²¹ a md was unable to access the nursing ED triage annotation, which would have inverse management; the patient died of subarachnoid hemorrhage.
• ▪ Exam results and evaluations were filed in multiple locations, contributing to the failure to notation the overall decline of a patient's vital signs and lab tests; the patient died of sepsis.
• ▪ A patient complained of "sudden onset of chest pains with burning epigastric pain, some relief with antacid"; Because the 'complaint' field in the EHR was besides small, the entry was noted just as "epigastric hurting"; no electrocardiogram was done and the patient experienced a cardiac event days afterward.
• ▪ An gild for blood was delayed reaching the lab; the patient expired before the blood arrived.
• ▪ A Pathology report of adenocarcinoma was delayed in reaching a patient's nautical chart until after inpatient discharge and no alert was sent to the patient's doc, resulting in the delayed diagnosis of cancer.

Similarly, user-related issues, including training and didactics, were identified in cases that spanned the spectrum of contributory factors:

• ▪ An obstetrician did not have EHR access and could not admission a patient's clinic notes documenting abnormal fetal size; the clinician stated he\she never received training or a password.
• ▪ A physician received an alert that the patient was allergic to amoxicillin simply ordered it anyhow, resulting in an allergic reaction.
• ▪ A patient developed amiodarone toxicity because the patient'southward history and medications were copied from a previous note that did not certificate that the patient was already on the medication.
• ▪ Results of a positive exam for C difficile infection went unnoticed, resulting in a seven 24-hour interval delay in starting treatment.

In the Ambulatory setting, issues relating to hybrid tape systems were the leading contributing cistron, referring to organizations where both paper and electronic systems were in use at the aforementioned time, or during a transition from paper to electronic, or ane EHR to another.

In the Inpatient setting, common problems were more evenly distributed, with over ten% of cases deriving from system design issues, breakdowns in communicating information, and having incorrect information in the EHR. In the Emergency setting, design issues were too mutual, along with a disproportionate number of cases where incorrect information was encountered in the EHR.

Major Allegations (Tabular array three and Fig. 2). Medication errors were the most common (76 cases, 31%) allegation blazon, followed by an almost equal distribution of errors related to diagnosis (69 cases, 28%) and treatment (medical, surgical, or OB\GYN handling (76 cases, 31%). A large majority of cases (90%) were represented past these 3 categories.

TABLE 3:

Major Allegations

Figure 2:

The Major Allegations in 248 Cases Involving EHR-Related Safety Issues.

Severity of Damage (Table 4 and Fig. 3). Over 80% of cases in each setting were medium or high severity. Cases deriving from ambulatory care were less likely to be lethal (eighteen%) than cases arising in inpatient or emergency settings (39%, Chi square P < 0.01), merely fifty-fifty in this setting, over lxxx% of cases involved medium or high severity of impairment. The severity of harm was comparable in both the user-related categories of error (85% medium or severe harm with 29% deaths) and the arrangement-related categories (81% medium or severe damage with 26% deaths).

Table 4:

Severity of Harm

FIGURE 3:

The Relative Caste of Harm in Cases from Ambulatory, Inpatient, and Emergency Settings.

Medication-Related Errors (Table 5). Medication-related errors accounted for the largest fraction of EHR-related errors overall (76 cases, 31%). Within this category, nearly one-half of the errors were related to medication ordering (35 cases, 46%), along with errors associated with improper medication management (19 cases, 25%) and assistants errors (12 cases, 16%). Ordering problems were the most frequent trouble in all three settings of care. Illustrative examples included these:

TABLE 5:

Medication-Related Errors

• ▪ The electronically signed discharge guild omitted the patient's warfarin; the patient was admitted days subsequently with a stroke.
• ▪ A exact order for morphine was entered without stipulating the upper dose limit; the patient go obtunded and expired.
• ▪ A patient previously on anticoagulation was admitted for GI bleeding; the medico intended to discontinue the anticoagulant merely mistakenly clicked on "continue Lovenox for habitation employ."

Diagnostic Errors. In both the Ambulatory and Emergency settings, diagnostic errors were the leading allegation. Of these 69 cases, 30 resulted in expiry. Including 2 cases that involved both types of issues, diagnosis-related cases seemed to more commonly involve user-related bug with the EHR compared to technology related problems (42 user-related problems with 19 deaths vs 29 engineering-related bug with x deaths, p for proportion of issues = 0.02). Of the 42 cases with a user-related effect, 32 were convalescent cases, and the dominant EHR-related codes were difficulty during an EHR conversion (16 cases), failing to appreciate a deteriorating clinical situation due to pre-populating or re-create\paste (x cases), and mis-routed information (7 cases).

Twenty eight of the diagnosis-related cases involved delayed diagnosis of cancer. Twenty five cases involved acute problems such as myocardial infarction (five cases), cardiomyopathies or endocarditis (v cases), pulmonary embolism (four cases), pneumonia (iii cases), or other infections (8 cases). The remaining cases involved delayed or missed diagnosis of fractures, HIV, and post-operative complications.

Word

The information presented in this study confirms that adverse events related to using electronic medical tape systems exist, that they are associated with an observable incidence of severe damage and death, and that they are encountered across the continuum of healthcare settings and all 15 of the sociotechnical contributing factors that were used to characterize these cases.

In regard to impairment, this data paints a unlike picture of the risk of injury from EHR-related problems than data obtained through patient safety reporting programs. A recent analysis of reported safety events related to health It in England identified 850 events reported from 2005 to 2011. Only 3% of these cases involved patient harm, although harm was noted to be 4 times more likely if the underlying causes involved human factors than if the causative factors were more technical.²² Another study of reported health-IT related safety events also found a very low rate of harm, with simply 1 death noted in over 3000 reported events.²³ Cases identified through a malpractice claims database are pre-selected for harm, as this is one of the cardinal elements of a malpractice claim. Even so, the findings of this study confirm that severe harm occurs at non-negligible rates. The actual incidence of harm cannot be reliably estimated from this information; all the same, it is more often than not agreed that safety events represented in malpractice claims are the "tip of the iceberg," insofar as the vast majority of cases, even cases that involve harm, practice not issue in suits.

The severity of harm was less in the ambulatory intendance setting. Nosotros hypothesize that this may reflect the fact that almost ambulatory patients have medical problems of lower acuity, making them less susceptible to harm, or that errors in this setting are more hands detected and rectified or mitigated.

Harm was appreciable in the bang-up bulk of cases, and thus in each of the different categories of EHR-related contributing factors. Nosotros interpret this to point that the specific category of EHR-related factors is less important than the clinical circumstances in which information technology is encountered. Equally an instance, a delay in obtaining a medication in the outpatient setting may be just an inconvenience, merely the same type of filibuster, for case obtaining blood to transfuse a patient who is hemorrhaging, tin be lethal. Similar observations have been in regard to the harm deriving from errors in the clinical laboratory; the patient's clinical circumstances outweigh the particular phase of laboratory testing (pre-analytical, analytical, or mail-belittling) in determining whether harm will be produced.²⁴ This is an important decision that should be validated in subsequent studies, because it implies that information technology will be incommunicable to prioritize which specific type of EHR-related error predisposition needs to exist addressed first—they are all of import and each carries the risk of damage.

Factors Related to EHR-Related Mistake

Cases were encountered across each of the major service lines. In each of these services, convalescent errors predominated, except for nursing-related cases. The authority of the ambulatory intendance setting over inpatient and emergency care settings (59% ambulatory) parallels the distribution of diagnostic errors claims in this database (57% ambulatory),²⁵ and probably reflects the total volume of patient encounters and intendance in each of these settings. Information technology is not possible from this data to make up one's mind whether EHR-related cases are more common or likely in whatever particular care setting or specialty service, although this information would be valuable to know, and will require report protocols that specifically address these questions.

The distribution of EHR-related contributing factors was not appreciably different between ambulatory and inpatient care settings, merely errors encountered in emergency intendance appeared to more commonly involve incorrect information in the EHR and grooming bug, compared to the other 2 settings. Although our study did not directly accost the factors that accounted for this observation, it is possible that the disproportionate frequency of grooming-related errors may chronicle to staff turnover in this setting, and the difficulty of grooming staff working night and evening tours.

The relative frequency of errors in medication management is not surprising, given the complexity of the procedure and the volume of orders being processed. The two steps that seem most error-prone are those that involve the physician, test ordering and medication management. Similar observations have been made in regard to laboratory-related error, also highly dependent on technology, where the most error-prone steps are those involving the physician, and not the laboratory per se.²⁶

An of import ascertainment from this study is that EHR-related issues accounted for less than 1% of the rubber events coded during the same period. Thus, in relation to the many other patient safe issues that lead to impairment, EHR-related cases comprise just a small minority, admitting an important ane.

Problems and Trends Identified

The data from this study suggests that interventions to reduce impairment should parallel the sites nearly at adventure (ambulatory intendance in particular) and the processes that account for the most errors (for example, medication usage, diagnosis) rather than prioritizing specific bug involving the technology per se, the users, or the interface between the 2. These sociotechnical factors were all associated with appreciable damage in this written report, as noted above.

Both venders and the user customs are already actively engaged in efforts to address the types of unintended consequences identified in this report. Indeed, the EHR offers the potential to accost many different patient-prophylactic bug that pb to adverse events.²⁷ The SAFER guides recently issued past the Part of the National Coordinator for Health Computer science provide specific consensus recommendations in this regard, focusing on both the condom apply of wellness informatics tools, as well every bit the application of these tools to improve the prophylactic of healthcare.²⁸

Each of the cases in this study indicates a specific vulnerability that providers should exist aware of and monitor to ensure that a similar problem doesn't recur during the care of their own patients. Looking across cases, several themes were apparent that represent productive areas where providers and their organizations could begin improving the safety of using EHRs:

1. The danger inherent in hybrid systems and EHR conversions: We identified repeated examples of injurious issues during periods when organizations are transitioning their record systems. Moreover, these conversions will continue to be common in the virtually term every bit organizations try to optimize user satisfaction and functionality by irresolute vendors or tape systems, embarking on an upgrade, or adopting new functionality. These transitions require a well-defined action programme and appropriate resource to ensure consummate and accurate data is available as rapidly every bit possible. Providers need to be informed of progress, whatever delays, and the specific functionalities impacted by the conversion. Providers demand constant reminders that these transition periods create greatly increased risk that the information needed for condom patient care may be missing or wrong.
2. The dangers of delayed, missing, or incorrect data, services, or actions: Many malpractice claims originated from limitations created by the EHR in providing the correct data, information or services needed for safety patient care. These issues were compounded by the expectation on the part of providers that the medical record system was working every bit they expected information technology should, when in fact information technology was not. Examples included delays in returning critical laboratory values, important pathology results that were lost or misdirected, pasted data that was incorrect, and blood products needed for urgent transfusion that was misrouted. Providers need to appreciate these vulnerabilities so that they tin take appropriate steps to validate data, to ensure timely follow upwards on tests that are ordered, or to ask straight about services or products that appear delayed. If key data is missing in the EHR, providers need to find it.
3. The danger of over-reliance on the EHR: As just noted, providers would be well served to be wary of situations where data is incomplete or maybe inaccurate. The electronic record is an ideal tool to support clinical judgment, but cannot non supersede it. Merely equally quality in clinical intendance involves constant monitoring and questioning to ensure that diagnosis and handling are correct, there should be a comparable level of vigilance and appreciative inquiry in regard to using the EHR. Data and information that raises an eyebrow should exist verified or rechecked.
4. The inherent risks using copy\paste functionality, over-riding alerts, and employing "workarounds." These are all well-known vulnerabilities.

In addition to these lessons for providers that would increase condom in using the EHR, we identified 3 major vulnerabilities that EHR vendors and management teams could address to meliorate safe:

1. Routing problems: We encountered repeated examples of laboratory results going to the wrong provider, documentation not being available to the providers who needed it, and assorted other problems of getting the correct data to the right provider. Given the complexity of today's health care systems, special intendance and attention is needed to ensure the right routing of information and services. It is imperative to understand how and why this data is being mis-routed and develop specific solutions that accost both system and user contributions.
2. Pre-population: Although implemented as a time-saver, pre-population by its nature creates the opportunity for data that is outdated or frankly incorrect to be repeated or misinterpreted. A patient'southward vital signs might indicate deterioration, but pre-populating a note with yesterday's results could mask this. It seems imperative that we explore the timesaving value of this program choice, with the vulnerabilities it produces. Is there a way for the "user" to exist alerted to the "auto-populated / repetitive" nature of the data they are trusting—and if so, will the "alert-weary" clinician actually have note?
3. Intrinsic cross-checking: An intelligent medical tape system should be able to notice a decimal indicate error in ordering a medication, as this would fall outside of the adequate dosing range. It would detect that an club for potassium in a patient already hyperkalemic is probably inappropriate. Predictive analytics could potentially forbid a substantial fraction of EHR-related condom concerns. Intelligent analytics of this type can be particularly constructive in detecting patients at risk for diagnostic error.²⁹

Relationship of these results to other studies. Cases represented in databases of patient claims are a rich source of information about agin events of all types involving patient condom. As an example, Bishop et al analyzed over 10,000 cases in the National Practitioner Data Bank.³⁰ As in our report, the predominant cause for a claim in ambulatory settings related to diagnosis. Similarly, diagnosis-related claims were the nearly common type in a recent systematic review of claims analyses in primary intendance, followed by medication errors.³¹

The specific role of wellness-IT in agin patient safety events has been examined predominantly by assay of reports submitted to patient safety organizations (PSOs) and other organizations. A study of 2 big PSO databases recently identified over 20,000 safety events involving health Information technology, 4.seven% of all the safety events reported. The most mutual category of identified errors were medication related.¹⁴ Equally in our study, issues were encountered across the sociotechnical spectrum.

Lookout event reports submitted to The Joint Commission comprise some other source of harm-related events. A recent report identified fourscore cases (2.iv%) involving the EHR out of 3375 sentinel events reported between Jan of 2010 and June of 2013.¹⁷ Over half of these cases involved a patient's death, and another 11% involved permanent injury. This report shares two common findings with the findings in our analysis: 1) cases involving the EHR made up only a small fraction of all safety-related reports, and two) the damage involved was substantial A major difference is that not a unmarried case of diagnostic mistake was included in the sentinel event reports, reflecting the fact that events reportable to The Joint Commission are focused nearly exclusively on treatment-related problems.

Implications for Agreement Safety Concerns Using Electronic Medical Records

The various etiologies of error identified in this study are representative of the error etiologies in many other studies, and spanned the sociotechnical dimensions.^32,33 Errors were found in all three of the major sociotechnical elements: involving the technology itself, the users of the applied science, and the work environment where care is provided at the interface between the two. These included problems with clumsy design features, breakdowns in information menstruum, copy\paste issues, missing or incorrect information, and problems relating to the transition from paper to electronic records, or from one EHR to a new ane. The relative frequency of problems involving transitions to a new EHR may reflect the fact that this study was conducted over a time span when many practices and organizations were just adopting new EHR systems, or advancing to a dissimilar one. At the same fourth dimension, information technology is likely that conversions and upgrades will continue to be common events given that wellness It is rapidly advancing, and both competition and innovation are abundant. In this case, the risks of EHR conversions, transitions, and hybrid systems will exist with us for some fourth dimension to come.

Advantages and Limitations of Studying Medical Malpractice Claims Data

From a research perspective, the apply of claims databases to evaluate unintended consequences of EHR adoption has both positive and negative qualities. At that place are 4 major advantages:

1. Claims data derives from beyond the continuum of health intendance, including both inpatient and outpatient intendance, including individual practices, in both academic and not-bookish settings. In contrast, information submitted through patient safety organizations derives virtually entirely from inpatient or hospital-associated data, and generally excludes events arising in private practice.
2. Claims data provides extensive text-based information and analysis from both medical and legal documentation in each example, facilitating the qualitative analysis of any given breakdown, and its contributing factors.
3. A related forcefulness is that the detailed information on each case increases both the sensitivity and specificity of coding. Although we did non mensurate sensitivity in this study we did assess specificity. The double verification of each case ensured that each case did in fact reverberate EHR-related impairment. Thus, almost 90% of the cases identified as being health Information technology–related in this study specifically involved the EHR. In contrast, a contempo follow-upward study of safe events submitted to a large patient rubber organization found that most a tertiary of the events submitted as health-It related were non, and over a quarter of the events which did involve wellness-It were not coded as such.¹⁴
4. Claims data uniquely identifies cases known to have acquired damage. Although impairment data can be extracted from reports of safety incidents to PSOs, these cases mostly identify cases with the potential for harm; harm is non a requirement for these reports to exist filed, and as nosotros have noted, cases involving severe harm may be frankly unusual in PSO-derived reports.

The limitations of this written report, and other studies using claims data, are also numerous and important:

1. The major limitation of studying claims data is the relatively small number of cases available for assay. Equally an example, just 248 cases were identified in the three yr coding period of this report, whereas a recent study of health IT–related events reported through a patient rubber organization found 191 instances in just 9 weeks,^fifteen and several thousand such events over an 8 year expect back.²³ Similarly,1100 health-Information technology related events were reported to an FDA safety database over a menstruation of ii and a half years,³⁴ and over 63,000 health-It related bug were identified in reports to another national database of medication errors.³⁵ The small sample size in our study prevents the states from addressing many fundamental questions, such as whether the safe use of EHRs, or wellness Information technology in general is increasing over time.
2. Because cases are reported from across the land, there is uncontrolled variability in regard to the EHR's used and the many institution-specific qualities that are relevant to health Information technology safety, such as resources, safety culture, and local health It expertise and champions.
3. Only a very small percentage of adverse safety events result in malpractice claims or suits. For this reason, data obtained from claims and suits cannot be used to estimate the actual incidence of error types, although it does provide insight into the relative frequencies.
4. Finally, the cases in malpractice claims databases oft reflect events that happened years ago. It is impossible to know if the etiologic bug identified in a given example however persist at that institution or whether they take been addressed in the meantime. The static nature of claims information makes it particularly unsuitable to evaluate the remarkably dynamic nature of health It adoption and development. It is fair to annotation, however, that bug that might exist "quondam" at one organisation may still be "new" at another arrangement that is at an earlier stage of EHR adoption; sharing key take chances data may therefore still accept considerable value.

In summary, limitations in current EHR systems, and how these are used to provide clinical intendance by healthcare professionals, can atomic number 82 to harm and death in some relatively small, but important fraction of cases. It is likely that EHR-related harm can be encountered in any healthcare setting and in any clinical service.

On balance, nosotros believe that the information presented in this report supports the value of conducting analyses of claims data to validate the importance of the problem, just conclude that a comprehensive appreciation of EHR-related prophylactic will require input from a range of unlike approaches and sources of information. This parallels the conclusion reached in other studies of patient safety events regarding the value of triangulating data from a variety of sources and perspectives.^36–38 In particular, research approaches are needed that tin provide additional quantitative data to accost the question of whether the safety of using EHRs is improving over time, and whether there are particular situations, technologies, or user behaviors that need to exist prioritized. In the concurrently, the types of errors revealed in this written report provide a wide range of safe problems that need attention. Healthcare professionals, their organizations, and health IT vendors can decrease the hazard of harm related to using electronic medical records by affectionate and addressing the lessons that these cases provide.

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APPENDIX A. CASE EXAMPLES OF HEALTH It–RELATED ERRORS, By CATEGORY Type

System Related Issues

System and software design

• ▪ Fentanyl society altered by a decimal point; patient died.
• ▪ Insulin social club defaulted to incorrect preparation (long vs short-acting).
• ▪ Fentanyl overdose resulting from failed auto-deletion of before orders of a lower dose.
• ▪ The EHR automatically "signed" a test result when in fact information technology had not been read; Patient did non receive results of co-existing liver cancer and was treated for lung cancer only.

Routing of electronic information

• ▪ Order for blood delayed reaching lab; patient expired before blood arrived.
• ▪ Disquisitional claret gas value misrouted to the wrong unit; patient expired from respiratory failure.
• ▪ Disquisitional ultrasound result routed to the wrong tab in the EHR; Md never saw the result until a year afterward; patient experienced delayed recognition of cancer
• ▪ Abnormal cardiac ultrasound results misrouted, would have prompted anticoagulation; patient died of stroke.

Organization dysfunction or malfunction

• ▪ Multiple reports of organization being "down," staff unable to access information; In one case, medication reconciliation could not exist completed, resulting in an injurious medication mistake.
• ▪ Computer crash caused loss of colonoscopy results; follow up delayed and next study disclosed colon cancer.
• ▪ Nursing staff unable to locate a previous nursing assessment and vital signs; RN asserted that the EHR had only "gone live" and kept "crashing"; delayed recognition of patient's deterioration.
• ▪ Physician not able to access nursing ED triage annotation, which would have changed direction; patient died of subarachnoid hemorrhage.

Integration problems and incompatible Systems

• ▪ Fetal demise followed past consent for "limited" chromosome testing. Pathology unable to admission the specific order, so did total chromosome studies not consented by the family unit.
• ▪ Delayed diagnosis of lung cancer; Primary care provider could not admission radiology studies at the time of patient visit; paper results filed without the Medico seeing these, staff assertive the results were available on line.
• ▪ OB patient requested tubal ligation at the time of her 4th planned Caesarian section. Noted on office record merely not integrated with the commitment room organization. Covering Doc delivered the baby but did non know/encounter the asking for tubal ligation; Patient became pregnant 6 months later.

Lack of or failure of Warning/Alarm/Decision Back up

• ▪ Pathology report of adenocarcinoma delayed in reaching patient'south chart until after inpatient discharge and no alert sent to patient'south physician; delayed diagnosis of cancer.

Fragmented information

• ▪ Test results in multiple locations; failure to note overall pass up of vital signs and lab tests; patient died of sepsis.
• ▪ Positive test effect for cervical cancer entered into trouble list; MD expected information technology to exist in EHR exam result section; mistake not discovered until patient's visit a year subsequently.
• ▪ RN entered Haldol society as 5.0 mg instead of 0.5 mg; MD meant to sign off on lab results, but signed off on the wrong lodge by mistake.

All other

• ▪ Pt complained of "sudden onset of chest pains with burning epigastric hurting, some relief with antacid"; Complaint field was too small; entry noted just as "epigastric pain"; no ECG done; patient experienced a cardiac event days later.
• ▪ Lack of follow upward of abnormal PSA; visit notes were sparse due to limited text fields and apply of a system that referenced problems by a number, non text.

User-Related Issues

User errors - miscellaneous

• ▪ Electronically signed discharge society omitted patient's Coumadin; patient admitted with stroke.
• ▪ Verbal club for morphine entered without upper limit defined; patient become obtunded and expired.
• ▪ Results of positive test for C difficile not noticed; 7 day delay in starting treatment.
• ▪ MD unable to discover pathology report in the EHR; called Pathology to go a exact written report, which was a normal result from the wrong patient; real patient died of cancer 3 years later, original report was abnormal.

Hybrid wellness records/Conversion problems

• ▪ Medication reconciliation list did not include Sotalol; residenct copied the ED medication list; patient went into Afib. The EHR did not list medications from the prior admission and did not interface with the inpatient unit of measurement.
• ▪ Patient underwent colonoscopy for bleeding per rectum just exam was incomplete. Dr. changed EHR'south which didn't convey the incomplete exam; patient had delayed diagnosis of colon cancer.
• ▪ Pediatric patient received ampicillin in the ER despite known allergy, which had been documented in the paper record simply not uploaded into the EHR.

Incorrect information

• ▪ Facility with new EHR dosage of Benemid copied over from paper tape incorrectly; patient received double doses, developed seizures and died.
• ▪ Patient previously on anticoagulation admitted for GI bleeding; Physician intended to discontinue the anticoagulant just mistakenly clicked on "go along Lovenox for home use."
• ▪ Ultrasound results never scanned into the EHR; delayed diagnosis of thyroid malignancy.
• ▪ MD intended to society Flonase accidentally selected Flomax from a drop downward card.

Prepopulating; re-create and paste

• ▪ History copied from a previous note which did not document patient's amiodarone medication; delayed recognition of amiodarone toxicity.
• ▪ Patient was to receive 6 injections of a medication; The EHR reflected 66 injections based on use of incorrect template.
• ▪ Incorrect conclusion that patient was on indomethacin when it was automatically pulled forward from an outdated medication list.

Grooming and education

• ▪ Roofing obstetrician did not have EHR admission and could non admission dispensary notes documenting abnormal fetal size; stated he\she never received preparation or countersign.
• ▪ Urologist failed to appreciate aberrant test results; CT results were placed in the new EHR simply Doc assumed he'd receive a paper re-create.

All other

• ▪ Amoxicillin ordered for patient allergic to penicillin had allergic reaction; Dr. over-rode the alarm.
• ▪ Oxycodone allergy overrode by Dr. which removed information technology from allergy list; on transfer to.
• ▪ Alerts on abnormal claret civilization ignored; patient died of endocarditis.
• ▪ Alert to NSAID allergy was ignored.

Keywords:

patient rubber; wellness information technology; malpractice claims

Copyright © 2015 The Writer(s). Published by Wolters Kluwer Health, Inc. All rights reserved.

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Source: https://journals.lww.com/journalpatientsafety/Fulltext/2019/06000/Electronic_Health_Record_Related_Events_in_Medical.1.aspx

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