Medical errors can seriously affect patients. While mistakes made may not affect health outcomes, sometimes fatal results may occur. A Johns Hopkins study discovered that over 250,000 people die in the United States each year because of medical errors. This makes it the third-leading cause of death, after heart disease and cancer. One of the medical errors that are harming patients pertains to medical record documentation. Below are a few examples of how mistakes in entering medical records can cause real injuries to people.
A Young Florida Woman with Headaches
A 19-year-old Florida woman received metaphorical headaches from blatant errors in her medical record. Because of a chronic illness she has, she visits many medical specialists. As a result, she and her mother always request her medical records after each visit. This allows them to keep track of her medical records in the same place. If it were not for her constantly requesting her medical records, she might not have been able to catch these mistakes in time for mistreatment or misdiagnosis. After a visit to a woman’s health clinic in 2016, she requested her records as she usually did. However, there was something peculiar about the records she received. There was a note in the record saying that she had two children. It noted that one was still alive, and the other one died shortly after birth. According to the dates associated with that note, she would have had to have given birth to the first child at age 13. This made little sense, as she had never been pregnant. It was also not the first mistake either, as a previous record erroneously noted that she had diabetes. She did not find out about that specific mistake in her records until a doctor had asked her questions about her blood sugar. It was only after her appointment that she found the records that note this error. Unfortunately for the woman, trying to remove the pregnancies she never had from the record was difficult. She called the doctor’s office, notifying them that she has no children and has never been pregnant before. The assistant on the other end kept insisting that she was wrong and that the records were accurate. This person also insisted this pregnancy would not have been on record if she did not notify the doctor’s office about it. According to a sociologist at the University of Pennsylvania, this is not an uncommon response. Doctors do not want to admit their mistakes, out of fear of being sued for medical malpractice.
How medical records errors may lead to fatal results
The Florida woman is fortunate that the errors in the medical records did not affect her own treatment. Sometimes, errors can affect a patient’s treatment significantly, and may indirectly cause their death. One such case involves an Ohio couple’s late daughter, who was diagnosed with a large tumor in her abdomen when she was about a year old. She underwent many surgeries and extensive chemotherapy before being declared cancer-free. However, doctors encouraged the couple to continue their daughter’s last scheduled chemotherapy session, which was to last three days. On the last day of treatment, the pharmacy technician filled the intravenous bag with over 20 times the recommended dose of sodium chloride. A few hours later, the couple’s daughter was put on life support and declared brain dead. She died three days later. This medical error was because the pharmacy technician filled the bag with too much sodium chloride, and this leads to such a tragic result. The young girl did not need that much sodium chloride, as her treating doctors already declared her cancer-free prior to her last round of chemotherapy.
Larger point… malpractice is killing us
People still cannot get their minds around the malpractice problem. According to the lead author in the Hopkins study, medical errors that have resulted in death are because of mistakes such as an incompetent staff, judgment or care error, a system defect, or a preventable adverse effect. This is alarming because it highlights the need for more competent staff and better training. Medical records errors, such as the one involving the Florida woman, are also most common than you realize. About seventy percent of records in the United States contain the wrong information. These mistakes can happen when a busy physician has multiple records open on their laptop. This can cause the copying and pasting of information into the wrong patient. They may also mistype a word that might change what they had meant in the records. For example, they might mix up the words “hypo” and “hyper,” which are antonyms of each other. Are these mistakes usually harmless? They are. But, for far too many, they are fatal. While the Florida woman was fortunate in not getting ill because of mistakes in her medical records, many others are not as fortunate.
Verdicts and Settlements Involving Medical Record Errors
YEAR / STATE
CASE / INJURY SUMMARY
RESULT
2019 – Montana
A woman underwent left eye surgery to implant an artificial lens. Following the procedure, she suffered myopia and emotional distress. The woman alleged that the ophthalmologist’s failure to order a new A-scan test caused her permanent injuries. She claimed he relied on unreadable medical records that were seven years old. The woman also claimed he misread them, resulting in the wrong implant being ordered. A jury awarded a $5,766 verdict.
$5,766 – Verdict
2019 – Alabama
A young woman inquired about birth control to an obstetrician. She underwent tests to determine her blood clot risk. The woman tested positive. However, the woman was prescribed birth control without knowing this. One month later, she presented to urgent care with respiratory issues and chest pain. She received antibiotics and was told to return if her condition worsened. Two days later, she returned with worsened symptoms. The woman presented to a newer physician, who could not access her medical records. Instead of being transferred to a hospital, she was discharged with an inhaler. The following day, the woman died from a pulmonary embolism. Her family alleged that the urgent care physician’s failure to access her medical records caused her death. They argued that had the physician accessed her records, he would have prescribed anticoagulants that could have saved her life. The jury awarded her family $9,000,000.
$9,000,000 – Verdict
2018 – California
A man presented to the emergency room with a fever, headaches, and other symptoms. The ER physician ordered a lumbar puncture and CT scan. The lumbar puncture showed high nucleated cell levels. Because of these results, the physician admitted him. While hospitalized, the man suffered permanent brain damage. He claimed the medical records software failed to include his positive herpes test result, delaying meningitis treatments, including the administering of Acyclovir. The man argued that this delay allowed his meningitis to cause severe brain damage. The hospital denied liability, arguing that they met the standard of care. This case settled for $1,000,000.
$1,000,000 – Settlement
2015 – Michigan
$20,000,000 – Verdict