Introduction
The management of patient data records is now more efficient due to Electronic Health Record. Improvements in the coordination of care are another advantage of electronic recording. In recent years, the frequency of electronic health records errors has also increased. This has led to significant patient safety concerns and other legal issues. Lack of understanding about patients suffering for EHR mistakes is important. All these factors are crucial for any lawyer working with an attorney who is trying to prove malpractice motivated by EHR Errors. In this article, we focus on the impact of EHR errors in the legal domain, focusing particularly on patient care and the compilation of medical records.
Understanding Electronic Health Record Errors
Definition of EHR Errors
The emergence of health information technologies has made the risk of EHR mistakes increasingly prevalent. These errors include problems in data entry such as omission of information, misrepresentations, alterations and an array of other issues that may compromise care services provided to a patient. They can happen within the context of data entry, verifications and sharing.
Types of EHR Errors
- Data Entry Errors: Mistakes made during the input of patient information, such as incorrect Data Entry Errors – errors committed while entering specific information such as history of medications, dosage, allergic reactions, and other medical information.
- Data Retrieval Errors – challenges that arise from failure to retrieve a specific set of information leading to misdiagnosis and even treatment.
- Problems in Interoperability: Issues arising as a result of the inability of separate EHR systems to communicate with each other and thus form coherent patient details.
- Medication Mistakes. Mistakes caused from prescribing a patient, giving out or injecting a patient medication because of the wrong input in an EHR.
Causes of EHR Errors
System Problems
• Graphic User Interface: A bad designed EHR interface will increase the rate of mistakes that can be committed at the data entry.
• Limited Provided Training: The healthcare providers may not be sufficiently trained in relation to the use of the EHR system resulting in high chances of making mistakes.
• Very Heavy Workload: Busy health care providers may not take their time to put in the data hence chances of making mistakes are high.
Personal Factors
• Overloaded Cognitive Capacity: The design of the EHR can easily disorient providers hence in response commit mistakes.
• Structural Communication Problems: Divergent communication attitudes between different members of the healthcare team may introduce errors in the patient records.
Legal Implications of EHR Errors
Establishing Negligence
To prove a case of EHR-related negligence, attorneys must establish the following elements:
- Duty of Care: The health care practitioner was supposed to provide the correct service and in good time.
- Breach of Duty: The practitioner must have failed to meet the expected level of care in those particular circumstances.
- Causation: The patient sustained injury due to the error that was incorporated in the EHR.
- Damages: As a result of the error, the patient was injured in quantifiable terms.
Common Legal Challenges
- Proving Causation: Establishing a direct connection between the EHR error and the patient’s negative outcome may not be easy.
- Defensive Medicine: A healthcare provider may assert that he or she has acted with reasonable care when claiming that the patient suffered quantifiable harm.
The Role of Medical Records Review
Importance of Medical Records
Medical records are critical in establishing the timeline of events and the quality of care provided. A thorough review can reveal:
- Triage Notes: The record of the patient’s first assessment and any possible errors of omission of commission in the care offered.
- Physician Orders: Confirmation of the treatment procedures that were requested and the time they were done.
- Patient’s History: Any medical information relevant to the treatment decision.
How Medical Records Review Supports Attorneys
- Identifying Patterns: Systemic problems in the healthcare facility that could have caused the EHR error can be revealed during the detailed analysis.
- Expert Testimony: Medical records are reliable evidence to substantiate an expert’s opinions on the reasonable standard of care and shortcomings.
Case Studies
Case Study 1: Overview of the Case
Overview: Because of an EHR data entry error, a 70 years old patient received the wrong medication which caused serious complications.
Challenges: The focus was on proving the negligence of the caregiver.
Solutions
• Medical Records Review: The patient’s EHR records were quad-checked to locate the error and set up the events sequence.
• Expert Testimony: A pharmacologist was invited to testify on the standard practice of treatment and prescribing medication prescriptions.
Compensation
• A settlement was reached that included payment for medical care, pain and discomfort, and modification of the facility’s EHR records and practices.
Case Study 2: Overview of the Case
Overview: A young mother with allergies was treating for allergic reactions and was prescribed medication that she was allergic to. The prescription caused severe allergic reaction.
Challenges: The challenge was posed by the defense who claimed that the prescribing doctor followed the standard practical care. The case became complicated.
Solutions
• Thorough Review of Medical Records: A review of the EHR was done to examine the allergies that were documented and why they were not adhered to.
• Expert Testimony: An allergist was invited to elaborate on the danger of the prescribed medication and the consequences of not following the documented allergies.
Compensation
• Consequence: The plaintiff won and received payments for health care, wages, and psychological trauma resulting from the incident.
Conclusion
While Electronic Health Records have led to much promise in the improvement of healthcare systems, they have also created new problems some of which are serious legal issues due to errors. This is a multi-faceted issue, and for attorneys, having expertise regarding the differences in EHR errors as well as the medical record review process is key in winning cases for their clients. Addressing the issues that this article seeks to fill gaps in literature is equally as important as addressing the neglected intricacies of EHRs in other articles.