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This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Yadav S, Kazanji N, C NK, et al. J Am Med Inform Assoc. 2017;24:140-144.
Compared to paper charts, electronic health records offer safety benefits for physician documentation including better availability and legibility. However, electronic documentation introduces new concerns, such as copy-and-paste practices (which can perpetuate errors) and lack of diagnostic reasoning in electronic notes. This study compared physical exam documentation in initial physician progress notes before and after implementation of an electronic health record. Investigators found more inaccuracies in electronic notes, but more errors of omission in paper charts. Trainee physicians' documentation had fewer errors in both paper and electronic formats. The authors recommend that hospitals discourage copied notes and encourage accurate documentation at the time of the patient encounter. The importance of the physical examination itself was discussed in a PSNet interview with Dr. Abraham Verghese.
A woman admitted to the hospital for cardiac transplantation evaluation is mistakenly given warfarin despite an order to hold the dose due to an increase in her INR level.
A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge.