Recent articles have highlighted both the benefits and risks of electronic medical records. The Pittsburgh Tribune-Review featured an article discussing the risks of electronic medical records in drug dosages. It noted that the ‘default’ settings of various drugs can cause the improper administration of medications, both in timing and dosage. Pennsylvania alone had 300 medical errors as a result of these default settings.
There is a countervailing view of medical records – one that sings the praises of reduction of human error in the maintenance of records. Some studies show that the electronic records themselves cause only 1% of errors. But can we rely on this information? Of note, there is a hole in the reporting. Unless drug companies or medical device manufacturers who are required to report ‘adverse events’, software companies are not under the same obligations. The errors that occur, once fixed (whether by an institution or the company itself) may well fade into the past, never to be recorded.
So what can you do to protect yourself from errors in your electronic records?
-Never answer the question “Is everything else the same?” with “Yes.” You don’t know what information is in the system and you could accidentally confirm something that is wrong.
-Be sure your medication list is accurate. Ask the person helping you to read off your current medications that are in the system. You’d be astonished at the medicines that remain on your profile long after you’ve stopped taking them. This can be particularly important with medicines like antibiotics that you only take for 10 days at a time.
-If a healthcare provider says something about you or your history that doesn’t sound quite right, ask them where they got the information. Someone else’s information may have been inadvertently entered in your chart.
-Be SURE to clarify body parts – never let anyone say “right, I mean left” when you’re talking about limbs or eyes or ears. Be sure your record lists the part you’re concerned about correctly every time.
Electronic medical records have tremendous potential to help us have consistent healthcare. With a vigilant attitude, you can be sure your providers get the best information!