Ohio residents may be surprised to learn that copying and pasting patient care notes made by other doctors and medical staff in electronic health records or EHRs is a very common practice. It is such an epidemic that one doctor and professor at a major medical university said that it has a name – “sloppy and paste.” Imagine you or a loved one is a patient in a hospital and have just undergone a major surgery. Your doctor makes a note in your EHR that you will require a certain dose of a medication.
Then another doctor reviews the patient’s record during the next shift and simply copies and pastes the previous doctor’s notes into your record without clarifying the note or when it was made. A nurse comes along, reads the second note and interprets it to mean the patient has not yet received the medication and administers a second dose. The result could be catastrophic for the patient as evidenced in an actual case.
The case involved a patient who did not receive life-saving medication due to a copy and paste error in her EHR, the patient died. Research studies show the use of copying and pasting notes in EHRs is becoming an increasingly more common practice and can lead to serious instances of medical negligence.
The problem is more widespread because there are multiple teams of physicians participating in the care of patients and they only communicate with each other through patients’ EHRs. One study examined 2,000 progress notes found in 135 patient records by 11 attending physicians and 62 residents in a Cleveland intensive care unit. Eighty two percent of the notes made by residents and 74 percent of the notes made by attending physicians contained more than 20 percent of copied and pasted text.
These rates have been confirmed in subsequent studies indicating the problem is only going to get worse as the numbers of medical facilities that use EHRs increase. One possible fix may be disabling the copy and paste function from the software but that has been deemed too extreme by some physicians and patient safety advocates.
Something needs to get done to protect patients from being exposed to medical malpractice such as medication errors and other forms of hospital or doctor negligence. Patients and their family members who have been harmed by the negligence of a doctor or medical facility do have the right to recover compensation for their injuries.
Source: American Medical News, “EHRs: “Sloppy and paste” endures despite patient safety risk,” Kevin B. O’Reilly, Feb. 4, 2013