Medical records are a key part of safe and effective healthcare. They document a patient’s medical history, medications, treatment plans, and more. Importantly, they help medical providers maintain an efficient chain of care and make informed treatment decisions.
However, errors in medical records can cause serious and even life-threatening consequences. For patients, these mistakes can lead to misdiagnosis, delayed treatment, incorrect medication, and other long-term harm that requires making a Philadelphia medical malpractice claim.
Common Types of Medical Record Errors
While technology has improved the accessibility of medical records, it has also increased the opportunity for errors to spread quickly across health systems.
These errors can take many forms, including:
- Incorrect patient information (wrong name, date of birth, or medical history)
- Medication errors related to dosage, omissions, or documentation
- Misdiagnosis or inaccurate diagnoses entered into the record
- Failure to document allergies or adverse drug reactions
- Duplicate records due to multiple patient profiles
- Outdated information that remains in the file after treatment plans change
- Clerical mistakes or misinterpretation of handwritten notes
Even seemingly small errors can have ripple effects on treatment decisions.
How Do These Errors Harm Patients?
The risks associated with medical record errors are wide-ranging and often severe. Some of the most serious consequences include:
1. Misdiagnosis or Delayed Diagnosis
When a patient’s symptoms are not accurately recorded, it can lead doctors to treat the patient for the wrong condition or not treat them at all.
2. Medication Errors
Medical records often guide prescribing decisions. An incorrect medication list or dosage in a patient’s chart can result in overdoses, dangerous drug interactions, or the administration of drugs to which the patient is allergic.
3. Surgical Mistakes
Surgical teams rely on medical records to confirm the correct patient, procedure, and site of surgery. Errors in documentation can result in wrong-site surgery, incorrect procedures, or other “never-events” that shouldn’t happen.
4. Unnecessary or Duplicate Testing
If providers do not have access to complete and accurate records, they may order duplicate tests or unnecessary imaging. This, in turn, leads to increased healthcare costs and potential exposure to radiation or invasive procedures.
5. Compromised Emergency Care
In emergencies, quick access to accurate medical information is critical. A deficient record can be deadly when decisions must be made quickly.
Can Medical Record Errors Lead to a Malpractice Claim?
Yes. If a medical record error leads to serious harm, the patient may have grounds for a Philadelphia hospital malpractice claim against the responsible healthcare provider.
To succeed, the injured patient must show that:
- A healthcare provider failed to meet the accepted standard of care
- That failure was due, in part, to an error in the medical record
- The patient suffered harm as a direct result
In many cases, proving that the provider relied on inaccurate records to provide treatment can establish liability.
How Can Patients Protect Themselves from Medical Records Errors?
Patients can reduce the risk of medical errors by taking certain steps. If you are concerned about such errors, you should:
- Request and review their own medical records regularly
- Inform providers about any known allergies, conditions, or medication changes
- Bring a medication list to appointments
- Ask questions if something seems incorrect or inconsistent
If you believe you were injured due to a medical record error, consult an experienced ER malpractice attorney in Philadelphia to explore your legal rights. Morris Wilson Knepp Jacquette, P.C. offers confidential consultations to help you understand your options.