• Sep 16

    Versio Staff

    Health Record Error: a personal account of a near-miss

    by  Versio Staff

    What should the average patient know when they go visit the doctor? Do you know that you can validate the accuracy of your own medical record?

    Recently, I was talking with a personal friend (we’ll call her Becky) who had just recovered from a surgical procedure. Prior to surgery, she had been in conversations with her physician and the surgeon regularly; she assumed this relatively common procedure would go smoothly. What happened was pretty shocking.

    Becky told me that as she was about to go under the general anesthesia, she saw the nurse preparing some additional medications for her. Groggily, she asked the nurse what the medications were. “This is Percocet, for the post-op pain.” Becky was startled, but still coherent enough to ask the nurse to repeat herself. When the nurse confirmed the Percocet, Becky explained that she is allergic to that drug and asked the nurse to review her chart. “Percocet isn’t listed here,” was the nurse’s response. “I don’t see it in your allergy list.” Fortunately, the nurse was able to get the doctor to change the medication order quickly and Becky’s surgery proceeded without a hitch.

    How did this omission happen? As it turns out, the health system where Becky had her surgery had just implemented a new Electronic Health Record (EHR). During the process of moving Becky’s medical record into the new system, some data did not convert properly and “fell out”. It never made it into her new EHR record! The conversion team did not have any way to validate that all of Becky’s data were captured, nor could they tell what dropped out. Fortunately, nobody was harmed in this incident. But what of other patients’ records? Could this happen to someone else? The answer is a resounding “yes!”

    According to a recent article from PSQH.com*, CRICO, a medical professional liability captive insurer, published its findings on a 2013 malpractice claims analysis. Just a few of CRICO’s findings, though preliminary, send a clear message: Caregivers need accurate information to make life-saving decisions, and there is much room for improvement in EHR design and implementation.

    There are several reasons why a record could be incorrect in an EHR.

    1. Faulty data entry: A patient’s height is 60 inches but is recorded as 60 centimeters, which distorts her body mass index (BMI).

    2. Unexpected conversion: The data is entered correctly, but the computer auto-converts it without the user noticing. For example, 2.5 changes to 25, which becomes a medication error when a clinician acts on the higher number.

    3. Hybrid health record/EHR conversion issues were a contributing factor in 16% of problems uncovered. A 4-year-old develops a penicillin allergy. It is noted in the paper record at the pediatrician’s office, which is transitioning to an electronic system. A relative who doesn’t know about the allergy takes the child for an urgent care visit in the same healthcare system. The EHR doesn’t yet reflect the new allergy, and a caregiver prescribes penicillin, triggering an allergic reaction.

    4. User error: A prescription for a short-acting drug is entered into the computer as the long-acting version. The order is refilled six times based on the erroneous information.

    What can you, as a healthcare consumer, do to ensure your health records and those of your family are correct? If your provider has an EHR, ask to learn about the patient portal – where you can go online to review your records. If there is no EHR, you can request copies of your paper records to review. Either way, we recommend you become proactive in the governance of your healthcare information. It could save your life.

    As more healthcare systems are implementing or changing EHR systems, be aware that migrating legacy medical data into an EHR is different than migrating other types of data. There must be stringent accuracy standards and the pervasive inconsistencies in source data make healthcare data migration a difficult task for even the most seasoned IT department.

    Healthcare providers, as you plan to bring your new EHR online, please consider a short conversation and a demonstration of our unique process which results in 100% data capture with near-perfect accuracy. This will be time well spent and will undoubtedly benefit your staff, your physicians, and the patients you serve.

    Contact us: sales@myversio.com or 253-277-0505. For additional information regarding our service lines, visit www.myVersio.com

    *Bradley Ruder, D. (2014, February 9). Malpractice Claims Analysis Confirms Risks in EHRs. Retrieved June 30, 2014, from http://www.psqh.com/january-february-2014/1825-malpractice-claims-analysis-confirms-risks-in-ehrs

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