Electronic health record (EHR) issues are coming up in malpractice lawsuits against ED providers. Seven such cases were included in a recent analysis of 216 closed claims occurring from 2010 to 2018 in which EHRs contributed to injury.1
“In several cases, inexperience with the EHR contributed to physicians failing to find all the information needed to make a correct diagnosis,” says Darrell Ranum, JD, study author and vice president of patient safety and risk management at the Doctors Company, a Napa, CA-based medical malpractice insurer that conducted the analysis.
In certain claims, the EHR contributed in some way to delaying treatment for a time-sensitive condition. This is especially relevant to the ED setting. “One unique element in ED cases is that patients are discharged from the hospital when the ER physician does not see abnormal findings,” Ranum observes. Also, patients often receive treatment outside the hospital before coming to the ED, but these data usually are not available in the EHR. “ER physicians may not have access to examination findings, test results, or X-ray reports from the earlier office or urgent care visits,” Ranum notes. This can cause problems such as medication reactions and delayed treatment.
Outdated, incorrect information from earlier ED visits or hospital admissions also popped up in some EHRs. “This resulted in diagnostic or treatment errors, and adverse events such as reactions to medications after the patient is discharged,” Ranum reports. Here are the specific allegations in the seven EHR-related ED malpractice claims included in the analysis:
• A patient with a history of breast cancer presented to the ED with chest pain. A CT for pulmonary emboli was negative for blood clots, but did it show probable liver and bone metastasis. The emergency physician (EP) noted this in his report. However, he did not sign the note until several weeks later — and the report did not show up in the EHR until the note was signed. Another EHR-related issue came up when the patient was admitted. “When the CT report was sent to the floor, it was scanned into the wrong section of the chart,” Ranum explains.
The EHR was fairly new at the time of the ED visit, so staff had limited experience using it. Since no one saw the CT report, the patient was discharged after cardiac treatment without learning about the findings. “Months later, the patient’s metastasis was diagnosed. The allegation was delay in treatment,” Ranum says.
• A woman came to the ED reporting pain in her lower right abdomen. A CT scan showed appendicitis. However, the results the EP found in the EHR stated the CT was negative for appendicitis. The patient was discharged.
“It was later discovered that the ER physician had read the wrong patient’s CT results,” Ranum says. The patient returned to the ED with severe pain and was taken to surgery. By that time, her appendix was perforated and she had an abscess. The patient recovered after a long illness.
• A 7-year-old boy presented to an ED with hip and leg pain after falling. The EP ordered two X-ray views. The radiologist ordered additional views that showed a fracture deformity of the femoral head physis. The radiologist did not call the EP about the findings.
“The ER physician looked at the two views that he had ordered, not realizing that there were additional views and reports to review,” Ranum says. This was not indicated in the EHR.
Since the findings were normal, the EP discharged the patient with pain medication. Days later, the boy returned to the ED with worse pain and reduced range of motion. A review of the X-rays performed during the previous ED visit revealed a fracture.
• The EP failed to identify a fracture of the lumbar spine with spinal cord injury. A 60-year-old man presented to an ED after a fall, and X-rays were taken of his pelvis, femur, and lumbar spine. The EP’s preliminary reading was normal. The radiologist’s reading indicated compression fractures of two lumbar vertebrae. Since the EP never saw the radiology report in the EHR, the patient was discharged home.
When the patient came back to the ED complaining of bowel and bladder dysfunction, the fractures were discovered. The patient was taken to surgery, but was left with bowel and bladder incontinence. The malpractice lawsuit named both the EP and the radiologist — but the EHR also was to blame. “It was discovered that the ER physician and radiologist were in the patient’s record simultaneously, and the system allowed only one person to enter information at a time,” Ranum says.
• A woman visited an ED with an adverse drug reaction from an antibiotic given at an urgent care center. The EP could not access the medical records in the EHR, and the patient could not remember the name of the antibiotic. “The EP prescribed the same antibiotic. The patient had a worse reaction, and was hospitalized,” Ranum notes.
• One patient with a Staphylococcus bacterial infection was misdiagnosed. The patient returned to the ED the day after the initial visit with worsening symptoms, but still was discharged without the correct diagnosis. During discovery, it became obvious that nobody had reviewed abnormal test results during the second ED visit. “The exam by the second ER physician appeared to have been copied and pasted,” Ranum observes. Documentation of the two ED visits were identical. Only the test results were different. Since the test results were missing from the clinical summary in the EHR, no one saw them before discharge. “This delayed treatment of the bacterial infection, which resulted in the patient’s death,” Ranum adds.
• A woman, 47, came to an ED reporting leg and buttock pain. The EP diagnosed lumbar sacral strain and ordered morphine. The pain continued, so hydromorphone also was administered. Shortly before discharge, the patient experienced breathing difficulty and lost consciousness.
After treatment with oxygen and naloxone, the patient was discharged home. During the night, the patient expired in her sleep. It was determined that obesity, obstructive sleep apnea, hypertrophic cardiomyopathy or dysrhythmia, and narcotics all contributed to her death.
Problems with the EHR came to light during litigation. Several ED staff testified their documentation had been entered incorrectly because of their lack of experience with the new system. “Inconsistent and missing documentation in the EHR complicated the defense of this case,” Ranum notes.
- Ranum D. Electronic health records continue to lead to malpractice suits. The Doctors Company, Napa, CA; 2019. Available at: http://bit.ly/2ShIOr1. Accessed Feb. 3, 2020.