We’ve come a long way from pen and paper charting. When I started nursing, all charting was handwritten nurses notes, orders, prescriptions, medication administration and daily care tasks. When the push came for facilities to move into a new computerized era, it was met with much fear, hesitation and push back, especially from seasoned nurses who felt inept to meet this new challenge. Little did anyone know how this would truly affect what we do as nurses and the dangers that lie ahead. Almost all clinicians had to adjust to the introduction of this technology that was offered as a way to increase productivity and continuity of care.
The most prevalent dangers when working with electronic charting are inaccurate, incomplete or even incompatible information spread from one program to the next, charting complacency and a decrease in time spent with the patient. KHN and Fortune examined more than two dozen medical negligence cases that have alleged that EHR’s either contributed to injuries, had been improperly altered, or were withheld from patients to conceal substandard care. In such cases, the suits typically settle prior to trial with strict confidentiality pledges, so it’s often not possible to determine the merits of the allegations (Schulte & Fry, 2016). Most vendors have a “hold harmless clause” protecting them from liabilities if facilities are ever sued for technological medical errors (2016). Simply put, there are factors working against you that can totally be out of your control, yet you still hold the burdon of punishment when something goes bad.
In 2016, it was reported that there were over 700 electronic charting endors offering different platorms being used in healcare, with each being customized for the facility it is being used in (Schulte & Fry, 2016). I am sure that number has grown significantly since then. The specific customization of these platforms has been proven to cause increased errors due to incompatability and transcription incongruity. This being the case, we may miss important information about our patients inadvertently resulting in harm.
One case cited by Schulte & Fry involves an error in transferring lab orders from one system to another, causing serious harm to a patient. It involved an order not being received, resuting in lab testing that was never performed. Critical values which should have been reported to the Physician were never available which would have helped to direct appropriate and timely care for the patient experiencing a life threatening event. This patient was in need of emergent antibiotic administration and since it was not given, the patient experienced long term consequences from irreversible brain damage from herpes encephalitis. The lawsuit involved the Physician testifying that the EHR system was faulty and the EMR Vendor stating that the Physician was negligent in pushing the correct button. Both ended up paying millions of dollars out of court as a settlement.
Next, charting complacency when there is less narrative charting and more check boxes to tick, supposidly showing tasks being perormed, such as assessments, medication administrations and other care provided. This concept of quick clicking gives way too much room for error and ambiguity when it comes to proving our daily care tasks. Areas scrutinized and missed with click charting are:
- Exactly what was found in an assessement
- Was this a complete or partial assessment
- Was there follow-up or notification made to other clinicians involved in the care
- Were there any interventions put in place other than the pre-filled responses
It’s not hard to see that we, even in our quest to take the best care of our patient’s, can be held accountable because of the inability to correctly chart our actions thorougly and accurately.
Finally, electronic charting is preventing nurses and all practitioners from providing hands on care, as this type of charting is requiring more administratve interaction . A report from the National Academy of Medicine revealed that on average, nurses and doctors spend 50% of their workday treating the screen, not the patient (as cited in Honavar, 2019). If we are spending less time with our patients, then it is inevitable that med errors and neglicance claims will occur. Detailed charting requires more time and manvering through the chart to find an appropriate area, so it is just being skipped in order to meet time guidelines also being imposed (but we’ll save that issue for another time).
We have to shift our focus to think of electronic charting as an addition to what we have been trained to do, instead of relying on it as a replacement. I expect more and more litigation resulting from technology, and as practiioners we must be intentional in what we do and work to ensure that the best care is still provided, and documented.
References:
Honavar, S. (2019). Electronic medical records – The good, the bad and the ugly. National Library of Medicine. Retrieved from pubmed.ncbi.nlm.gov/32056991/
Schulte, F,. & Fry, E. (2019). Death by 1,000 clicks: Where Electronic Health Records Went Wrong. Fortune. Retrieved from kffhealthnews.org/news/death-by-a-thousand-clicks/