Almost every hospital uses an electronic health record (EHR) system, and often they can help reduce medical record errors and streamline data entry. However, a new study shows there are various issues that might crop up when entering data into EHRs.
It’s easy for providers and other staff members at your facility to succumb to the pressures of efficiency while using your EHR. With so many patients and so little time, taking shortcuts is inevitable and understandable. But the little mistakes that happen when trying to be fast can cause big problems.
“Electronic Health Record–Related Events in Medical Malpractice Claims,” a study in the Journal of Patient Safety, reveals that health IT-related mistakes can cause adverse patient effects of moderate-to-high severity.
According to the study, the most common malpractice claims filed in relation to health IT were about errors involving medication (31%), treatment complications (31%) or diagnoses (28%).
3 data entry strategies
Reminding your staff members to stay vigilant when keying in data can help, but there are other ways to ensure minor mistakes don’t cause trouble for patients and staff. Medical Economics recommends the following strategies:
- Closely monitor systems during times of transition. Many of the mistakes found in the study took place when organizations were upgrading their EHRs, switching vendors or otherwise changing their systems. Make sure your staff members know when changes are coming and what those changes will be, and train them thoroughly on any new systems.
- Keep an eye on copying and pasting. Just copying and pasting data into patient records can cause confusion, especially if there’s little or no new info added at a visit. It may seem like a time-saver, but in reality, it opens your records up to errors. Plus, other providers or staff looking at the record may not be able to understand what happened during the encounter.
- Use templates sparingly. Using point and click options or prefab templates in your EHR might feel like a quick, simple alternative to repeatedly typing in the same info. However, research from Perspectives in Health Information Management shows that many patient records have similar or identical entries when completed with templates. If you can’t avoid templates, train staff on how to use them properly, and remind them to double- and triple-check the info they input.
EHRs and other health IT systems are a major component of health care, and they’re not going away any time soon. So making sure your staff knows how to use them without causing patient safety problems – or exposing you to legal scrutiny – is worth the effort.
