System Dangers: How EHRs Can Contribute to Medical Malpractice Claims

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System Dangers: How EHRs Can Contribute to Medical Malpractice Claims

Wednesday, June 10, 2015

by David B. Troxel, MD, Medical Director, The Doctors Company

In 2013, The Doctors Company began coding closed claims using 15 electronic health record (EHR) contributing factor codes (for system and user factors) developed by CRICO Strategies and back-coded all claims to 2007. EHR-related claims frequency is increasing. Twenty-six such claims closed in the first two quarters of 2014, 28 claims closed in 2013, 22 closed in 2012, 19 closed in 2011, and two closed between 2007 and 2010. These 97 EHR-related claims that closed from January 2007 through June 2014 are the subject of this analysis.

User factors contributed to 64 percent of these EHR-related claims, and system factors contributed to 42 percent. The following tables and representative claims illustrate how EHR system and user factors contributed to the 97 closed claims. Some claims contained more than one contributing factor.

EHR System Factors:
Technology, Design, and Security Issues

10% -- Failure of system design
9% -- Electronic systems/technology failure
7% -- Lack of EHR alert/alarm/decision support
6% -- System failure - electronic data routing
4% -- Insufficient scope/area for documentation
3% -- Fragmented EHR

Claim: Lack of EHR Drug Alert

A dialysis patient transferred to a skilled nursing facility. There was an active hospital transfer order for Lovenox. A physician evaluated the patient on admission but made no comment about the Lovenox order. During the first dialysis treatment, there was active bleeding at the fistula site. Heparin (anticoagulant) had not been given. Nursing did not inform the physician of the bleeding. During the second dialysis treatment, there was uncontrolled bleeding from the fistula. The patient exsanguinated and expired. Experts were critical that there was no EHR High-Risk Medication Alert.

EHR User Factors:
EHR-Related Issues Attributable to Users

16% -- Incorrect information in the EHR
15% -- Hybrid health records/EHR conversion
13% -- Prepopulating/copy and paste
7% -- EHR training/education
7% -- EHR user error (other than data entry)
3% -- EHR alert issues/fatigue
1% -- EHR/CPOE workarounds

Claim: Incorrect Information in EHR

A patient was seen by her cardiologist for hypertension. In the written medical record, her blood pressure medication had been increased to 25 mg once a day. Office staff entered the order into the EHR as twice a day. The prescription was filled. The patient missed her follow-up appointment. Seven months later, she went to the ER with numbness and weakness. Her potassium level was low. The cardiologist corrected the prescription error and gave her potassium.

We also analyzed the 97 EHR claims to determine the most common allegations.

Top Allegations in EHR Claims

27% -- Diagnosis-related (failure, delay, wrong)
19% -- Medication-related:
     7% -- Ordering wrong medication
     5% -- Ordering wrong dose
     7% -- Improper medication management

The 2011 Institute of Medicine report, Health IT and Patient Safety: Building Safer Systems for Better Care, concluded that the information needed to analyze and assess health IT (HIT) safety and use was not available and that our understanding of the benefits and risks of EHRs was anecdotal. The report recommended creating a government agency that would systematically and uniformly collect data to investigate harm and safety events related to HIT. The Office of the National Coordinator for Health Information Technology is now developing a plan to create a Health IT Safety Center.

Contributed by The Doctors Company. For more patient safety articles and practice tips, visit

David B. Troxel, MD, is medical director of The Doctors Company. Dr. Troxel is clinical professor emeritus, School of Public Health at the University of California at Berkeley. He is past president of the American Board of Pathology and the California Society of Pathologists.