The majority of healthcare providers use electronic health record (EHR) systems but these systems are not infallible. This analysis used closed malpractice claims from the CRICO malpractice insurance database to identify whether the EHR contributes to diagnostic error, the types of errors, and where in the diagnostic process errors occur. EHR contributed to diagnostic error in 61% of claims, the majority in outpatient care, and 92% at the testing stage.

Medical scribes are increasingly being utilized to reduce the time burden on clinicians for electronic health record (EHR) documentation. In this secondary analysis, researchers identified three themes for safe use of medical scribes: communication aspects, teamwork efforts, and provider characteristics.

Electronic health records (EHR) may have unintended negative consequences on patient safety. This review identified 11 articles focused on the relationship between EHR use and diagnostic error. EHR issues fell into three general areas: information gathering, medical decision-making, and plan implementation and communication. The majority of issues were a related to providers’ cognitive processing, revealing an important area of research and quality improvement.

… efficiency, quality, and safety. … Ash JS, Corby S, Mohan V, et al. Safe use of the EHR by medical scribes: a qualitative study. J Amer Med Inform Assoc.  Epub 2020 Oct …

Reporting complete patient information during clinical rounds is important for achieving an accurate diagnosis and informing clinical management. Prior research has shown that data is sometimes omitted or inaccurately communicated on rounds. This observational study compared patient data shared by trainees and medical students on ICU rounds to that contained within the electronic health record. Researchers analyzed photocopies of trainee and student notes as well as audio recordings of their oral presentations. For the 157 patient presentations included in the study, they found all contained data omissions and that other team members on rounds supplemented a minimal amount of data missing from student and trainee presentations. The authors recommend additional oversight and education of trainees with regard to data presented on rounds.

… study sought to test whether safety problems documented in a simulated patient electronic health record were recognized …

… … J Grad Med Educ … Resident work hour limits have been a controversial patient safety strategy. Discussing a recent adjustment to the duty hours requirements, this … new standards on both the medical profession and society. A recent PSNet perspective described the 2017 work hour …

… suggest that inaccurately communicated laboratory data is a prevalent and underrecognized patient safety concern. …

This study found that laboratory values designated as "abnormal" or "panic" in the electronic health record, which are considered passive alerts, are very common for patients in the intensive care unit. The authors suggest that these passive alerts contribute to the pervasive problem of alert fatigue in the intensive care unit.

… study, medical residents missed patient safety issues in a simulated review of the electronic health record. Repeated …

… asked to review the electronic medical record (EMR) of a simulated intensive care unit patient, indicating that the …