Malpractice Dangers in the Patient Handoff

Mark Crane, BA


May 17, 2017

In This Article

Electronic Health Records: Blessing or Curse?

In theory, the use of electronic health records where all physicians involved in the patient's care can see each other's notes should reduce communication and handoff errors. But in practice, the systems are hardly foolproof.

"Electronic medical records are now everywhere," said Alan Lembitz, MD, chief medical officer of COPIC, a professional liability carrier based in Denver, Colorado. "They fundamentally change not just the way we document, but workflow and even the way we think.

"The big issue is the concept of signal to noise," he said. "These systems generate a lot of noise, a high volume of data. But what happens when we lose the real signal, the important information we want to convey, amid all the noise? Why am I being asked to consult? What do I tell the next doctor down the line?

"I put a note in the record at 10 PM and then assume that the next doctor will see it when he checks in at 7 AM," said Lembitz. "That assumption gets doctors in trouble because the information often isn't accessed. There isn't a closed loop where you get a confirmation of what you've entered. The salient information can get lost in all the data that are required in these systems.

"In the hospitalist world, with patients moving from office to clinic to imaging center to the hospital, we're relying on a process without active confirmation. Couple that with low signal and high noise, and it's easy to see how things get lost," he said. "If information is critical, it's important to make sure it was received. Ask the next doctor to confirm that he saw it. Sometimes, we need to pick up the phone to make sure."

CRICO's Dana Siegal agrees. "We talk to each other a lot less these days. Nurse and doctor teams can go an entire shift without ever speaking to each other. The attitude is, 'I put it on the electronic record. You should have seen it.'"

"We lose that human interactive brainstorming with each other—the ability to bounce ideas off each other," she said. "Instead, we make the handoff to a computer and then expect the computer to hand off to the intended receiver. But maybe that doctor didn't look in the right place. There are lots of screens involved, and the systems aren't easy or intuitive.

"Things get lost in all of the data that electronic systems demand," Siegal continued. "Vital information isn't always highlighted, and incidental findings that could be crucial are buried."

"For example, a patient goes to the emergency department after an auto accident. Radiographs show that there may be a rib fracture. But the radiologist also notes a small shadow on the lower left lobe of the lung," she said. "That finding gets put at the bottom of the report, or maybe another screen. When the patient is finally diagnosed with lung cancer 3 years later, they go back and look at the old film. The finding was there, but wasn't seen because of the cumbersome electronic record."

It's not uncommon for the system to route data to the wrong receiver, she adds. "A test result, lab value, or radiology report is sent to the wrong provider far too often. So it's never seen. It's just out there in no man's land and isn't reported to the patient.

"Cutting and pasting is common and contributes to problems," Siegal said. "Someone wrote in the record, 'no allergies.' That gets copied and pasted over and over. If you look at the box of recorded allergies, it may say the patient is allergic to sulfa drugs. The subsequent doctor only looked at the top summary."

"Some systems don't connect well with each other," she continued. "Often, there's just user error. Drop-down menus are difficult. In some larger hospitals, primary care and specialty doctors use the same system. Even then, there may be different systems for labs, outpatient imaging, and so on, and the information could be on a different system."

Darrell Ranum said younger physicians who never used paper records believe that electronic records meet their needs. They like the accessibility and the ease of documenting routine histories, physical exams, and other patient assessments.

"We've found that electronic record systems are rarely the underlying cause of patient harm," he said. "More frequently, there are deficiencies in the use of these systems."


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