Malpractice Claims Report: EHR Documentation Errors Still Far Too Common

A recent review of 10 years of medical malpractice claims from medical professional liability insurance provider Coverys explores how safety efforts since To Err Is Human have not delivered optimal results. The report’s analysts contend the findings raise vital questions for the healthcare industry at large.

Data from the Boston-based Coverys shows improvement in select areas such as increased patient engagement, flattened hierarchies enabling staff to raise concerns, increased teamwork, and better sharing of information. However, many areas remain largely unchanged. Some key findings of the report, which was derived from nearly 12,000 events pertaining to more than 20,000 closed claims at Coverys across a 10-year period from 2010 to 2019, include:

The average indemnity paid for physicians’ medical malpractice claims increased 20 percent from 2010 to 2019, to $411,053.

Over the 10 years of claims analyzed, there was an average of 4.4 claims per every 100 physicians. Obstetrics and surgery have the highest claims rates.

Surgery and procedure-related allegations are the most frequent, followed closely by diagnosis-related allegations—combined, they account for 57 percent of allegations and 59 percent of indemnity paid.
Persistent risks that lead to poor patient outcomes involve the interweaving of communication, process, and cognitive issues, each capable of impacting reliable patient care.
The practice of anesthesia is now highly data-driven and claims are declining. A focus on simulation training, human factors engineering, and evidence-based decision-making has resulted in improvements.

Related to electronic health records (EHRs) specifically, the report notes that in theory, they provide better data and a centralized capture of everything relevant to a patient’s clinical profile. However, serious issues are evident, the report’s authors contend. For instance, users may be looking at the wrong dropdown, the wrong screen, the information might not have been updated, or the documentation was done on the wrong patient. Some EHR-specific findings include:

51 percent of indemnity paid on EHR events were attributed to events that resulted in death. The majority of EHR events were tied to medium-to low severity injuries (59 percent).
Documentation is the most common risk management subcategory for EHRs, making up 72 percent of all EHR-related risk issues. This is attributed to users looking at the wrong dropdown, the wrong screen, the information might not have been updated, or the documentation was done on the wrong patient. Other prevalent risk areas include system issues such as confusing system design and incorrect patient information due to a system conversion and general EHR usability.
Diagnostic-related allegations comprise both the highest percentage of events as well as the highest indemnity payments in EHR events. Total indemnity payout for diagnosis-related EHR events is $11 million more than for medication-related EHR events, which is the second-most financially severe allegation category.
HIPAA security issues made up only approximately 2 percent of all EHR-related risk management factors.

One specific event that the report describes involved a 66-year-old female with a history of chronic obstructive pulmonary disease (COPD) who presented to the ER with complaints consistent with rib fractures and COPD exacerbation. She was admitted to the hospital under the care of a hospitalist. Her Keflex (cephalexin) allergy was documented in the EHR and alternative medications were administered during her stay. But despite that documented allergy, the hospitalist gave her a prescription for Keflex at discharge. She collapsed shortly after taking her first dose, eventually suffered an anoxic brain injury, and tragically died shortly after.

The hospital’s discharge protocol prohibited handwritten prescriptions and required they be entered in the EHR for easy medication reconciliation, according to the report. But hospitalist violated the discharge protocol in several ways, the researchers found. Violations included that the prescription was: 1) handwritten, 2) not entered into the EHR, and 3) not checked against the patient’s documented allergies.

“Data provides a glimpse into our past to inform the future, what I call signals,” Robert Hanscom, vice president, risk management and analytics, Coverys, said in a statement accompanying the report. “We see promise in a decade’s worth of data and embrace decision-making based on robust data analysis. The ability to parse and examine claims and event data from many angles enables us to understand trends, reveal fresh insights, and make recommendations to help improve patient safety.”

One other area to keep an eye on is telehealth, as the researchers note the COVID-19 pandemic has demonstrated the potential and importance of telehealth, and they anticipate it will grow exponentially. As the shift to telehealth continues, risk issues that may come to the surface include overreliance on technology, failure to appropriately document care, diagnosing clinical conditions without an in-person encounter, and lack of a traditional clinical evaluation, they add.

According to the report’s authors, “Improvement efforts, including legislation, regulation, strong leadership, and collective efforts are not showing a dramatic impact on what we refer to as ‘the tip of the iceberg’—malpractice claims. Some would argue that preventing liability is perhaps the most challenging aspect of performance improvement, but we believe otherwise. With focused attention on the vulnerabilities that are at the root of the ‘worst of the worst’ cases, proactive steps to create a safer, more reliable healthcare environment can help prevent these outcomes.”