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.

… and communication . The majority of issues were a related to providers’ cognitive processing, revealing an … and quality improvement. … Dixit RA, Boxley CL, Samuel S, et al. Electronic health record use issues and diagnostic error: a scoping review and framework. J Patient Saf. …

… 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 …

… and that other team members on rounds supplemented a minimal amount of data missing from student and trainee …

… 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 …

Residents and fellows frequently failed to identify serious clinical abnormalities when asked to review the electronic medical record (EMR) of a simulated intensive care unit patient, indicating that the design of the EMR may affect situational awareness.