Two reports on the risks related to electronic health records (EHRs) reveal the broad range of alleged and actual user and system mistakes in recent EHR-related malpractice claims. The pace of these cases has grown rapidly over the last 10 years, the research indicates.

In a study of closed claims by The Doctors Company, a medical liability insurer in Napa, CA, the data indicate that the EHR typically is a contributing factor in a medical malpractice claim rather than its primary cause. Of all claims closed by The Doctors Company from January 2007 through June 2014, 0.9% (97 claims) had EHR-related contributing factors. In the follow-up study of all claims closed from July 2014 through December 2016, 1.6% (66 claims) had EHR-related contributing factors. (The study is available online at:

The following are key findings from The Doctors Company report:

• System factors, such as technology and design issues, lack of integration of hospital EHR systems, and failure or lack of alerts and alarms contributed to 50% of claims.

• User factors, such as copy-and-paste errors, data entry errors, and alert fatigue, contributed to 58% of claims.

• More EHR-related claim events are occurring in patient rooms and fewer are occurring in hospital clinics/doctors’ offices.

• Obstetrics/gynecology remain the top specialty in which these claim events occur.

The findings are “modestly reassuring,” says Robert Wachter, MD, chair of the Department of Medicine at the University of California in San Francisco.

“The number is not as high as I might have expected, but the problem is still real,” Wachter says. “The report demonstrates that even though one of the promised benefits of the electronic health record was to improve safety, and I believe they have, there are hazards in these systems. They’re demonstrable and measurable, and we can take steps to reduce EHR-related harm.”

Wachter draws attention to the data related to hybrid systems, those in which paper systems and electronic systems, or two electronic systems, try to mesh.

“There can be a transitional period where you have one part of your system on an EHR and another part is still on paper, and we’ve seen that that is a situation where a lot of things can go wrong with information not making it into the system or being distorted once it enters the electronic record,” he says. “Similar issues occur when you move to a new EHR but you do so in phases, with some parts of your operation still working with the older system. These are scenarios that conspire to threaten patient safety and require the utmost vigilance once you know you are in that risky situation.”

Another report by CNA, which provides risk management services for healthcare organizations and professionals, concludes that an “optimized” EHR may reduce diagnosis-related professional liability claims in the ED.

Healthcare organizations often complain about the challenges that accompany the advantages of EHR use, says Chris Heckman, vice president of underwriting with CNA Healthcare.

“Unfortunately, these electronic health record systems have not always been designed with patient safety and risk management considerations as their paramount objectives,” he says. “As a result, the limitations of this technology, and the negative habits it can engender among users, must be acknowledged as potentially affecting both quality of care and legal defensibility in the event of a claim or lawsuit.”

The CNA report examines major EHR-related issues and presents strategies designed to help protect patients, ensure quality of care, and minimize liability exposures. (The report is available online at: The overuse and abuse of the copy-and-paste function is a big concern.

The following are the top EHR-related risk management strategies recommended by CAN:

• establish policies and procedures delineating appropriate use of the copy-and-paste function;

• require ongoing education regarding proper use of the copy-and-paste function;

• consider adopting a voice-activated dictation system for the EHR;

• investigate the option of using software technology;

• audit EHRs on an ongoing basis;

• respond to EHR reviews or audits that reveal potential chronic misuse of copy-and-paste;

• consider EHR-based simulation training of residents and the medical staff to improve the efficient access to critically needed patient care information.


• Robert Wachter, MD, Chair, Department of Medicine, University of California, San Francisco. Phone: (415) 476-0909. Email: