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Can Errors on My Patient Record Lead to Medical Malpractice?

Making a spelling error in an email or writing down the wrong date for an appointment can be embarrassing but it usually doesn’t result in anything serious. However, errors on your patient record can have disastrous consequences. The wrong medical dosage, wrong patient information, or even the wrong site of a surgical procedure can result in serious injury, unnecessary pain, and can even be fatal. 

When a medical error is caused by a doctor going outside of standard practices and it causes an injury or harm, it may be considered medical malpractice. In a medical malpractice claim, the injury victim can recover money damages for their losses, medical bills, emotional distress, and pain and suffering. It is important for the victim to make the person responsible pay for their mistakes. 

You may not be sure if you even have a case but don’t give up, just because you’re not sure. A quick call to a medical malpractice law firm can help you understand whether you may have a case. Gilman and Bedigian can help you understand your legal options to recover injury compensation. Contact our office today online or by phone at 800-529-6162.  

What Are Different Types of Patient Record Errors

A patient’s medical record is like a personal history of the individual, containing information about their current health, past health, family history, and treatment plans. When a new doctor or surgeon reviews a patient’s health record for the first time, they can review the medical records to get a full summary of the patient and patient care up to the moment. The patient’s medical record can be extremely valuable but there can be problems with relying solely on the medical documentation. 

When there is an error in the patient’s record, it can compound problems. Even if a patient corrects a doctor that there is something wrong in the record, it may not always get corrected. Updating one chart may not be retroactive to correcting all the patient’s charts. If there is an error in the patient record, it can continue to cause problems for the patient, including resulting in improper treatment plans, misdiagnosis, and delayed diagnosis. 

Because medical records are such a central part of patient care, there can be many different types of patient record errors that can lead to medical malpractice. Some types of patient record errors include: 

  • Illegible writing
  • Improper abbreviations or shorthand
  • Prescription errors
  • Electronic record errors
  • Wrong patient/wrong site/wrong procedure errors 

Handwriting Confusion and Medical Injuries

Bad handwriting for doctors is the source of jokes but there can be a dark side to poor penmanship. When handwriting is difficult to read or illegible, it can be misread by other doctors and healthcare workers. Illegible prescriptions and medical record notes can cause delays in treatment and improper medical care. According to a report by the Institute of Medicine (IOM), 1.5 million injuries occur each year because pharmacists and healthcare workers misread sloppy handwriting. 

Many in the medical industry are calling for an end to handwritten records and prescriptions. However, some doctors still operate in the ways they were trained decades ago, relying on pen and paper, even if it can cause serious injury because of confusion and misinterpretation. 

Improper Abbreviations and Medical Mistakes

Many medical injuries involve doctors using shorthand and abbreviations that are subject to confusion. Historically, doctors used several abbreviations, often from Latin, for medical terminology. These practices are being discouraged because the symbols and designations can cause confusion. 

According to the Institute for Safe Medication Practices (ISMP), error-prone abbreviations, symbols, and dose designations should never be used when communicating medical information. Some examples from the list include: 

  • OD as “once daily” can be confused with o.d. as “right eye” (oculus dexter)
  • Per os means by mouth, orally, but can be confused with OS for the left eye (oculus sinister)
  • q1d as “daily” can be mistaken as q.i.d. “four times daily”
  • I.U. as “international unit” can be mistaken for I.V. for “intravenous” 

Prescription Errors and Medication Injuries

Medications are supposed to improve patient care by helping to heal, relieve pain, and treat other medical conditions. However, the wrong dose, wrong drugs, or dangerous drug interactions can cause serious injury. Patient record errors can lead to medication injuries and malpractice. 

Some common causes of prescription errors include: 

  • Wrong drug
  • Wrong dose
  • Wrong route of administration 
  • Wrong patient 
  • Drug name errors
  • Wrong frequency

Another problem with drug documentation is that there are several medications that have similar names and spellings to other drugs. According to the Pennsylvania Patient Safety Authority, 25% of medication errors were caused by confusion involving prescription names that sound alike or looked like another drug. For example:

  • Chlorpromazine and Chlorpropamide
  • Dimenhydrinate and Diphenhydramine
  • Prednisone and Prednisolone
  • Hydralazine and Hydroxyzine

These prescription errors can be made by the doctor, pharmacist, hospital, or by the healthcare provider administering the drugs.

New Technology Requirements and Patient Record Errors

Medical record keeping is moving away from paper records to electronic records. Some doctors are still transitioning over to electronic health record systems. Electronic records are supposed to make things easier and simplify communicating health care information across multiple doctors, hospitals, and health care systems. However, there are downsides of electronic health record systems

A common problem with medical records is assuming that once information is entered, the next care provider will immediately have access to that information. Unfortunately, the next provider may be operating on their prior knowledge of the patient without checking the updates. Doctors may also overlook the updates based on confusion in interpreting different health information formats from other doctors or other electronic health record systems. 

Another problem with electronic health records (EHRs) is “alert fatigue.” According to the Maryland Health Care Commission, alert fatigue begins when alert pop-ups occur continuously when doctors are working in the health record systems. Users may become distracted by the alerts, which leads some doctors to disable the alert function altogether. 

The alert functions can warn the medical professionals about serious issues. However, the alerts are often something the doctor is already aware of and does not need to see. Unfortunately, when the doctor disables the alert function, they may never see the alerts, which could result in serious injury. 

Wrong Site or Wrong Patient Errors

It can be easy to mix up directions like right instead of left, or mix up someone’s first name. However, with medical care, even the simplest mistake can have dire consequences. Imagine if a doctor thought they were supposed to amputate the left leg instead of the right leg. Or a patient record was updated with the information from another patient with the same last name. These kinds of mix-ups actually do occur in medical care. 

Wrong patient/procedure/side/side errors are known as “never events.” A never event is never supposed to happen unless there was negligence. Even though it seems like it would be almost impossible to make such a serious error, wrong patient injuries happen all the time. For example, a patient in Connecticut went in for surgery to have a cancerous lesion removed from the 8th rib. However, surgeons removed the 7th rib, which had no signs of cancer, leaving the cancerous rib in place. To make matters worse, the medical team lied to the patient about the error. 

According to a survey by the American Association for Hand Surgery, “Wrong site surgery is estimated to occur 40 times per week in hospitals and clinics in the USA.” These errors can be caused by failures in: 

  • Scheduling
  • Pre-op/holding
  • Operating room
  • Organizational culture 

For example, using unapproved abbreviations, medical record cross-outs, and illegible handwriting can result in operating on the wrong patient or the wrong site. During pre-op or holding, inconsistent or incorrect surgical documentation can cause mix-ups. In the operating room, when doctors and surgical staff fail to properly verify the patient, procedure, site, and side, it can result in dangerous errors. 

Chicago Patient Record Error

One way you might not expect to find an error in your medical records is to be incorrectly labeled as a user of illegal narcotics. A patient in Chicago was wrongly noted in her medical records as a user of illicit drugs. The patient found out about the error when she got a call from a disability benefits agent about her drug use. As she had never used cocaine before, the patient was shocked to get the call and wanted the errors corrected. 

There is a stigma associated with being labeled as a drug user. Doctors may be more reluctant to prescribe narcotic medications, even when it is medically appropriate. For example, after a surgery, the doctor may typically prescribe strong opiate drugs like vicodin or oxycontin. However, if the doctor sees the patient is an illicit drug user, they may change the prescription to something else, leaving the patient suffering unnecessary pain. 

Can You Correct Medical Record Errors?

If you find out about errors in your medical records, it is important to take steps to correct those errors. You can go to the doctor’s office or hospital and request to change or amend your health record. The health care provider is supposed to respond to your request. If the health care provider created the incorrect information, they should amend the incomplete or inaccurate information. If your provider does not act on the information, you can submit a statement of disagreement to the provider. 

However, it is important to understand that if you correct one record, the misinformation may be around somewhere else. You may have to be proactive in making sure that you continue to question the health care provider about their medical records to make sure your records are correct. An uncorrected mistake could lead to medical injuries or other complications. 

Do I Have a Medical Malpractice Case?

One of the biggest hurdles injury victims face is taking the initial step of talking to a medical malpractice lawyer. Even for injury victims who are sure their injury was caused by a medical error, it can be difficult to make a phone call to a law firm to talk about their injuries. People have lots of different reasons for being hesitant to come forward. 

Many patients are just not positive that a medical error was the cause of their injuries. It is common to explain away a medical error as a risk of medical care or just a side effect of healthcare in the United States these days. It is important to come forward because reporting your injury may actually make a difference in how other patients are treated in the future. The financial motivation of paying out for a medical error can provide a greater incentive for hospitals and health care providers to improve patient care. 

Another reason people are hesitant to come forward after suffering a medical error is that they don’t want to blame their doctor or the health care system. It is common to make excuses for a doctor who seems overstressed, overworked, or overburdened. However, it is important to remember that your health is at issue. A medical injury can have long-lasting impacts. An unnecessary injury can cost you time and money, and may continue to cause pain or other complications for years into the future. 

Some patients think their case may not be worth much and don’t want to go through the hassle of a lawsuit just to cover their medical bills. However, you should make sure you understand the full extent of your injuries and losses. Even if your insurance company is paying your medical bills, there can be other losses associated with a medical injury, including pain and suffering, loss of income, and future medical needs. 

A medical malpractice attorney can look at your case, review your medical records, and help you understand the basics of a medical malpractice claim. With an experienced attorney on your side, you can recover the maximum damages for your injuries. Contact a law firm that handles medical malpractice cases like yours. Contact Gilman & Bedigian online or at 800-529-6162 for a free consultation.

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