Researchers are surprised to find that errors are common in medical records

The medical records of hundreds of patients in a Sydney hospital’s cancer genetics service have been reviewed due to malpractice.

According to St. Vincent’s Hospital, deficiencies such as poor documentation, incomplete information and lack of genetic counseling were found in about 520 medical histories.

In about 20 records, errors were found that carried potential risks – even if the patient was not ultimately harmed – such as providing incorrect information and advice.

From time to time, such cases make the media headlines. Some examples of poor quality medical records are related to individual errors. Some are related to the way electronic patient record systems are designed.

These and other reasons mean that errors can occur when records are created, accessed and shared.

There is a huge potential for errors

Medical records describe the symptoms, conditions or problems to be treated. They include information about medication intake, diet, mobility, social history, family problems, observations, test results, and the language the patient speaks. Health care providers also document the recovery plan and progress. Therefore, records must be correct, complete, and up-to-date.

However, the scale of medical information sharing and documentation is enormous.

On average, every day in Australia there are more than 33,000 hospitalizations, more than 112,000 outpatient services and more than 24,000 emergency department visits.

Millions of specialist letters and discharge summaries are transferred to the My Health Record electronic system each month.

Every interaction with a health care provider requires entries in the medical record.

For example, a patient in an urban public hospital is likely to be seen in a day by at least three nursing teams, two or more junior doctors or registrars, and a specialist. Physical therapists, speech therapists, and other allied health professionals may also be involved in the patient’s care. Health professionals keep records on paper, in electronic medical records, or a combination of the two.

In addition, millions of medical records are updated by general practitioners or allied health professionals outside of hospitals.

What are the most common errors?

Accurate and timely medical records should enable staff to make safe clinical decisions and ensure quality and continuity of care. However, a number of reviews and studies have found errors, including those related to medications.

One review looked at how adverse drug reactions were recorded in the electronic medical records of a major Australian hospital. It found that half of the recorded reactions did not contain the minimum information needed to inform doctors about further treatment. One-third of the records misclassified the type of reaction.

A study of medical records in Australia and New Zealand found at least one simple error in medical records in about 94% of cases. These included illegible medication names, missing information and incorrect documentation of allergies.

One U.S. study found that written errors, such as unclear documentation or failure to use clear language, were among the most common errors in the records analyzed.

What happens when errors are present?

Errors in medical records can spread, affecting how health care providers communicate with each other about a patient, which can affect treatment.

Missing or inaccurate records can affect evidence gathered as part of a criminal, judicial or medical malpractice investigation.

Because some hospitals’ funding depends on the number and types of patients and interventions recorded, inaccurate records can affect healthcare budgets.

When inaccurate records exist, national and international collection of correct medical information can be compromised.

What causes errors?

Errors in medical records are caused by missing or incomplete information, including when health care providers fail to document changes.

Difficulty finding important information quickly or delays in reporting new information can contribute to errors, misdiagnosis and inappropriate treatment. This may be due to the ease of use of the electronic medical record, the cumbersome or disorganized nature of the paper record, or the busyness of health care providers.

Health professionals have noted that using a mixed record system (using both paper and electronic records) can cause problems.

In addition, there is “record bloat” where staff copy and paste information from one place to another. This contributes to the retention of incorrect information. This is a well-known danger that leads to errors, stress, and wasted time.

Abbreviations used in medical records, especially medication charts, can be misunderstood or misinterpreted.

An Australian study found that one in three medication errors were due to technical problems and caused by poor design or functionality.

In a Swedish study, patients examined entries in their medical records. Almost 36 % of patients found an error and more than 26 % found an omission. About 18 % of the patients were offended by the content of the records.

What can we do?

Improving the accuracy of medical records is not solely the responsibility of healthcare providers, although they certainly have an important role to play.

Health care providers can ensure that medical records are complete, accessible, accurate, readable, and durable.

Workplaces, such as hospitals, can emphasize the importance of documentation and how poor practices can lead to errors and contribute to safety and quality issues.

IT companies can develop electronic medical records that support how health care providers communicate with each other and how they work.

Patients can ask their health care provider to correct errors found in their records, including in the electronic system.