Potential Liability Risks of Electronic Health Records

Thomas Fleeter, MD, and David H. Sohn, JD, MD

Due to federal incentive payments, electronic health records (EHR) are rapidly becoming a part of the U.S. healthcare landscape. Although EHRs may offer opportunities to improve health care, electronic record keeping may also result in unforeseen liability exposure for physicians.

For example, consider the following scenario: In the preoperative holding area, a nurse enters the patient’s relevant health history into the hospital’s EHR. The patient’s history of sleep apnea is buried in the nursing note section but not recorded in the paper chart, and the patient does not mention it when questioned by the surgeon or anesthesiologist. After the surgery, the patient receives intramuscular narcotics overnight. At 3 a.m., the patient is found unresponsive and expires from a respiratory arrest. During the root cause analysis, the nurse’s note reflecting the history of sleep apnea is revealed, highlighting the danger that can occur when electronic and paper records are not accurately coordinated.

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