How Do Medical Record Errors Lead To Medical Malpractice? November 9, 2023.

Doctor writing on a notepad.

Have you ever found an error in your medical record? If you have, was it a serious error? Surprisingly, medical records are not always accurate, even though they should be. Even if the error isn’t serious, medical professionals are responsible for having accurate information regarding their patients. 

According to a 2016 study, Johns Hopkins Medicine estimated that more than 250,000 Americans die each year due to medical errors. Other research suggests that the number of deaths from medical errors could be as high as 440,000 deaths per year. This number depends on what healthcare providers count as a medical error. Errors often go undocumented because many medical professionals don’t want to face repercussions from the error, which is unsettling in itself. But, it also makes us wonder- How many of the deaths could have been prevented if the patient's medical records were correct?

The unsettling statistics unfortunately don't stop there. In a 2-year medical record study, done from 2018 to 2020, 29,656 participants read through their records to determine if there were any errors. Out of these participants, 4,830 (21.1%) of them determined that there was an error in their medical records. 2,043 (42.3%) of them said that the error was serious or somewhat serious.

What Is Included In Medical Records?

Medical records are legal and medical documents that are a detailed account of a patient's medical care and history.

 Medical records include:

  • Vaccine history
  • Past medical history
  • Medication taken
  • Allergies
  • Test results
  • Diagnoses
  • Treatments and procedures done
  • Progress notes
  • Summary of doctor's visits

Under the Ohio Law Revised Code 3701.74, patients can request a copy of their medical records. To request the medical records, the patient or the patient's approved representative would need to submit a request to their healthcare provider.

In the last few decades, healthcare providers have switched over to electronic health records, or EHR. This is simply a digital medical record. These are used to decrease the risk of inaccurate medical records because many patients have access to the EHR. This way patients can review and correct their records if needed. This also removes the risk of not being able to read doctor’s notes, since everything is typed out. Even though EHRs decrease the risk of errors in patient records, mistakes and inaccurate information could still be present.

Types of Medical Record Errors

Common types of medical record errors include: 

  • Prescription errors
  • Illegible handwriting
  • Inaccurate patient information
  • Lab errors
  • Incorrect abbreviations
  • Transcription errors

Prescription Errors

Prescription errors could include incorrect information about what prescriptions the patient takes, the wrong dosage, or prescribing the wrong medicine. If there is an error in the medication dosage this could lead to the patient not taking enough, or taking too much of the medication. The wrong medication being prescribed typically happens when the medication names are very similar. For example, the medications “Amaryl” and “Reminyl” have similar-sounding names. But, Amaryl is used to treat type 2 diabetes, while Reminyl is used to treat dementia. Taking the wrong prescription or taking the wrong dosage could lead to serious consequences.

Illegible Handwriting

We all are aware that doctors are notorious for illegible handwriting. Bad handwriting can lead to medical professionals misreading doctor’s notes. Messy handwriting can be from doctors overusing their hands during the day, or because they are writing notes quickly. But, this does not eliminate their responsibility if someone misreads their illegible handwriting. 

Something like messy handwriting may not seem like a big deal, but it makes up for hundreds of medical errors each year. This is another reason why many healthcare providers have moved towards digital records, so errors from illegible handwriting are diminished.

Inaccurate Medical History

The medical history of a patient could be incorrect if information is copied and pasted from patient to patient. This could lead to tests, diagnoses, or procedures on your medical record that you have never had done. 

A survey was done to see how many healthcare providers copied and pasted clinical notes. The survey results showed that 90% of physicians who took notes electronically used the copy-and-paste function to write parts of them.

Laboratory Errors

A laboratory error occurs when a medical professional delays treatment due to incorrect or false lab results. The delayed treatment of many diseases will make it harder to treat. More aggressive treatment options may be necessary the longer it goes misdiagnosed. 

For example, if a patient goes to the doctor to get screened for cancer and the lab results come back negative, then the doctor obviously won’t treat them. If the lab test was incorrect and the patient did have cancer, then this could lead to long-term consequences.

Incorrect Abbreviations

Abbreviations can easily get misread if they are very similar. For example “QD” means daily, “QID” means four times daily, and “QOD” means every other day. So a medication that is only supposed to be taken one time a day could easily get misread as four times a day. Depending on what medication it is, it could lead to an overdose.

Transcription Errors

The Cleveland Clinic defines medical transcriptions as audio recordings made by a healthcare provider that are transcribed into written medical reports. If the provider is talking too fast, or not talking clearly then this could lead to errors in the reports.

Preventing Medical Record Errors

Thankfully, the healthcare industry has come a long way with information transparency and now many patients have access to their medical records at the touch of a button. Even though patients can make sure their record is accurate, medical professionals are still responsible for making sure your records are error-free and up to date.

In depth training in how to properly document and update patient records should be implemented in every healthcare facility. A time requirement should also be set in place to update medical records, so they are updated in a timely manner. Another way to prevent record errors is to make sure all written documentation is clear and easy to read. 

To make sure there are no errors in your medical records, reach out to your healthcare provider to see if there is an electronic health record you can see. If your provider does not have an EHR set up, then you can request your medical records from your provider by using the steps stated above.

If you find a serious error in your medical records, be sure to contact your healthcare provider immediately to get it fixed. If there is a non-serious error, like your address or phone number is incorrect, you can correct the error with a pen by crossing it out. Then, write the correct information next to it. If you are looking at your records via EHR, and there is a non-serious error, you should be able to easily correct the information on the website.

Contact Our Medical Malpractice Attorneys

Medical professionals are responsible for keeping accurate and up-to-date records of all of their patients. If you have suffered an injury due to an error in your medical records, then you may be able to file a medical malpractice claim. 

Our attorneys at The Mellino Law Firm are highly experienced in medical malpractice cases. To see if you have a case, contact The Mellino Law Firm today. Call our office at (440) 333-3800 or fill out our contact form and an attorney will reach out to you.