5 Common Errors In Patient Record Keeping...
Updated: 7 days ago
...And How Tech Can Overcome Them
Let me kick off this blog with the following three stats around inaccuracies:
One in every five patients not matched to the correct record*
70% of records contain an error of some sort**
Errors during the placing or transcribing of prescriptions lead to 65.7% errors*
These are some alarming statistics especially when you factor in that errors made on a person’s medical records can have life altering and even potentially fatal consequences.
It also doesn’t matter whether your organisation is using paper records or electronic health records (EHRs) as they are both susceptible to data errors.
But what are the main errors being made? And if we can identify them can technology solutions be put in place to help mitigate the risks being posed?
A survey carried out by Derbyshire NHS Community Health Service*** asked respondents to state what they thought were the main areas of error/omission from a patient record.
The results were very interesting and from analysing the findings the following five areas look to be the most common ones causing errors in medical records:
Omitted data and signatures
Illegible handwriting and ambiguous abbreviations
Covering up errors
Inaccuracies, especially of date
Using Technology to turn the tide against human error
All of the above five areas have one thing in common, which is that there is an element of human error at play in each. Fortunately, from reviewing this list it is apparent to me that there are technology solutions on hand which can help reduce and even eliminate these mistakes altogether.
1. Omitted data and signatures
Let’s start with one of the most serious issues and that’s missing data and signatures. Without certain key information (e.g. drugs taken or observation data) it can make a patient record pretty meaningless and lead to delays in patient care while tests and observations are repeated. Also without a signature the chain of patient care is in doubt as you are unable to ask the person who previously treated a patient for advice and it stops you from carrying out any necessary auditing required for clinical governance.
Fortunately these omissions are easy to tackle with technology. By specifying which data fields are required it prevents the data enterer from moving on to the next stage until the form has been completed correctly. This helps breed best practice across your organisation.
Within our ARCEMS software we have similar processes in place. Required fields when raising an incident, PRF, survey etc are common and the system will ask for passwords (in lieu of a signature) at key parts of the process.
2. Illegible handwriting and ambiguous abbreviations
The handwriting aspect of this part is obviously easily overcome by using a digital interface to capture patient data. With regards to the ambiguous abbreviations this is something that is also fairly straightforward to stop.
To ensure consistency and clarity across the board it’s best to pre-define all of your organisations agreed abbreviations and then add them into the software you are using. These can then be used to populate drop down lists (rather than open text fields) throughout the patient recording process. Not only does it make it easy for all to understand but it can help speed up the data entry process too - win win.
We’re aware of this issue from working closely with our customers and we have developed ARCEMS so that the system can be fully customised by each customer to match terminology used at their organisation.
3. Unprofessional Terminology
The NHS survey gave examples like ‘dull as a doorstep’ ‘lovely child’ and ‘normal development’ as examples of what it deemed unprofessional terminology. Whilst at first glance they might not seem that bad - at least it shows notes were being taken right? - it can lead to issues due to the ambiguity of these terms.
This is the one area on the list that technology cannot fully eradicate but it can be a big help. Open text fields will always be subject to bad practices as anything can in theory be written (that’s more of a personal development issue to stop this) but software can be set up to keep everything else in line.
Let’s use the patient survey feature in ARCEMS as an example. This is setup to guide users through the process of logging observations and the recording of injuries, interventions, illnesses and drugs administered. This helps limit the opportunities a user has to add in their own words and it keeps things nice and consistent (and professional) across your organisation.
4. Covering up errors
Another serious one at number 4. Some people own their mistakes, others like to distance themselves from them which is causing this issue on patient records. Going back into a record and changing data after the fact to cover up a mistake is unethical and stops clinical governance from being carried out correctly.
It is possible to use technology to prevent this from happening by locking patient records so they are unable to be reopened. If your software can’t do this, it should at least provide you with time stamps for when data was accessed and edited so you can review the timeline of events.
In our software ARCEMS, we allow customers to lock a patient record for this very reason and we also provide administrators with full audit logs of when data was interacted with. This gives them peace of mind that no cover ups after the fact can slip through.
5. Inaccuracies, especially of date
The final common error follows on nicely from the previous point. Having accurate records is vital if hospitals, air ambulances, critical care transfer teams etc are to meet the requirements put before them around clinical governance.
Clinical governance isn’t red tape and bureaucracy, it’s in place to reassure the public that they are receiving the best treatment as hospitals are being held to the highest standards.
Technology can really make a huge difference here (Read our previous blog on tech supercharging clinical governance). Every interaction, note taken, medicine prescribed will be time stamped (to the second) down to an individual patient level allowing hospitals to see exactly what happened, when, by whom and to which patient.
Could your organisation be doing more?
Hopefully the above has shown the important part technology and in particular EPRF software can play in improving the quality of patient records by reducing errors. Ultimately it all leads to better patient care which is what we’re all looking for.
Does your organisation have systems or software in place which allows these errors and omissions to be a thing of the past? If not, our team is on-hand to demonstrate how ARCEMS can help improve your EPRFs.
Call us - 0191 8090 272
Email us - firstname.lastname@example.org