Health Care Situation: Medical Error Due to

Health Care Situation: Medical Error Due to Doctors' Bad Handwriting Identify a health care news situation that affects a health care organization such as a hospital, clinic or insurance company. I have identified the following health care news situation as the topic of my paper: "Poor Handwriting of Doctors and its implied risks for the Patient, Hospital and Medical Malpractice Insurance." Poor handwriting of physicians resulting in poor legibility of entries into patients' medical records carries very dramatic risks for all above-mentioned interest bearers.

It can result in severe health danger for the patient and - in extreme situations - even cause a patient's death. Doctors' bad penmanship has long been seen a problem within organized medicine and the patient safety movement. Three American Medical Association (AMA) policies dating back to 1992, urge doctors to "improve the legibility of handwritten orders for medications" and review all orders for accuracy and legibility after writing them.

The policies also encourage physicians to note the "purpose" of a prescription to "avoid confusion on the part of either pharmacists or patients." Physicians with poor handwriting are advised to use direct, computerized order entry systems or at least to print or type medication orders. And they should avoid using decimals, nonstandard abbreviations or the letter "u," which can easily be misread as a "zero" or as shorthand for "units" (see Prager, L.O. (22/29 November 1999, p. 1). Bruner and Kasdan (p.

2) cite a case reported in the medical journal Lancet, where a physician prescribed an asthmatic patient "Amoxil," an anti-infective. The pharmacist misinterpreted the word "Amoxil," written poorly in lower case on the prescription, and dispensed "Daonil," an anti-diabetic drug. This resulted in severe and dangerous hypoglycemia for the patient. In another case reported by the same authors (p. 2), a misfiled prescription of drug resulted in the death of a patient in Texas. A Texas jury awarded the patient's family $450,000.

The physician was required to pay half of this award, and the pharmacist the other. The jury later indicated they would have gone much higher if the plaintiff's relatives lawyer had put a price tag on the case (see Prager, L.O. ( 22/29 November 1999, p. 1). Bruner and Kasdan are of the opinion that the dangers of misrepresentation are even greater when the physician's signature is illegible because under such circumstances a nurse cannot easily reach the prescribing physician for clarification.

The authors cite a described in Medical Trial Quarterly in 1981 where a nurse in this instance misinterpreted a physician's order for a cardiac medication and injected the dose instead of administering the elixir form of the medication resulting in the patient's death. Furthermore, illegible handwriting in the medical field is costly because hospital staff will have to waste costly time attempting to decipher these orders (see Bruner and Kasdan, p. 2; Berwick, D.M. & Winickoff, D.E. (1996), p. 1657).

Finally, illegible medical records fail to communicate important information which is in particular alarming where emergency services are involved (see Bruner & Kasdan, p. 3). Poor legibility of medical records has also several severe legal implications. Very often the patient records will be the most important evidence in defense of a medical malpractice claim when healthcare organizations are involved in civil litigation of a patient. Without a legible patient record, efforts of defense against allegations of improper medical treatment and care may be weak (Glondys, B. (May 2003), p. 1).

An illegible record indicates comprise of clear communication between clinical and professional staff. In the minds of the jurors involved in the finding of responsibility of a doctor for medical malpractice, it may create the assumption that an entry in the medical record was improper and may thereby impair the doctor's (and the hospital's) defense. It may happen that the jurors see a connection between the poor quality of medical treatment administered to the patient and the poor legibility of his medical record.

If the medical record in court is read to the doctor to refresh his memory of details of his course of treatment in order to help her recall a given case, an illegible writing will not be of great value, especially if years since the treatment has elapsed (see Glondys, B. ibid). One has to take into consideration that the relevant statute of limitations in general provides a 2 1/2-year time limit for litigation starting with the date the cause of action for the medical malpractice accrues.

If the patient undergoes "continuous treatment" for the same medical condition with a doctor, the 2 1/2-year period of limitations against the doctor will start to run even later, e.g., from the date of the last treatment which will considerably improve a patient's legal ability to bring a medical malpractice claim in court.| Even worse are cases where the doctor can hardly read his own records.

If, for example, the doctor reads his or her own records, and says that he has order lab work to be done, but the jury cannot decipher the doctor's handwriting, the jurors may not believe that the doctor-defendant in a failure-to-diagnose case actually did prescribe lab work. As Johnson (21 May 2010, p.

1) very vividly describes it, the plaintiff's attorney might argue: "So only you and God know what the record says." Poor handwriting in medical records may not only have legal ramifications for the doctor who made illegible entries in a patient's record but also for the hospital employer. In most cases, a patient-plaintiff will not only sue the doctor for medical malpractice but will join the hospital in his lawsuit based on a theory of vicarious liability for the doctor's negligence.

If the doctor is found responsible by the jury for administering wrong treatment due to illegible recording of patient data, the hospital very often will also be held responsible for the doctor's omission due to organizational negligence. Against that legal background, the Court of Appeal of Louisiana in Norton v.

Argonaut Insurance Company (111 So2d 249) stated that physicians have a duty to make their intentions "clear and unmistakable" and that the physicians must "make certain" of the lines of communication between them and anyone who may execute their orders (see Bruner & Kasdan, p. 3). As the number of legal malpractice cases based on claims of bad handwriting of physicians goes up, the cost of legal malpractice insurance follows suit.

Examine and evaluate how organizational structure and governance, culture and focus (or lack of Focus) on social responsibility affected or influenced what happened. I think that the medical culture and organizational structure of hospitals are the most prominent factors affecting reliance on poor legibility of a doctor's handwriting resulting in poor legibility of medical records. Physicians are used to writing on paper and handing it to someone.

From the cultural, ethical, social responsibility and not the least economic point-of-view both doctors and hospitals want -- and quite rightly, for all these reasons -- to see as many patients per day as possible. For most physicians, the fastest way to do that is to write with pen on paper, not to put data into a computer interface (see Gibson, Stan (2009-2011), p. 1). Electronic systems are not as fast as a physician's pen.

The faster it is to put the patient's data into his medical record, the better the system from a doctor's perspective. Making use of EMRs will take the physician more time and effort. Doctors want to see the patient and get back to their office to see the next patient. A slowdown of their work due to an obligation to make use of a computerized medical record system might cause a lot of chaos at least in its initial stages of implementation.

That's where the biggest pushback is seen from the physician's perspective (see Gibson, Stan. (10 February 2010), p. 2). I would imagine that hospital's argumentation will be very similar. Leingang (2003, p. 1) states that poor handwriting among physicians is (also) rooted as a bad habit due to busy work schedule and has been responsible for wrong prescriptions and treatments.

Recommend what resources will be allocated to prevent this situation in the future and what ethical issues may be tied to this decision In my opinion, the one intervention that has substantial potential for improving the legibility of medical records is computerized Physician Order Entry (POE) sometimes also called Electronic Health Records (EHR) or Electronic Medical Records (EMR) in which doctors make use of technical solutions.

Among them are dictation systems for all prescriptions, letters, notes and orders; computer order entry; and typed, pre-printed prescription pads and order pages for computer generated prescriptions as recommended by Bruner and Kasdan (p. 4). As healthcare organizations adopt more sophisticated technology, medical records are frequently word-processed (see Glondys, B. Journal of AHIMA 74, No. 5 (May 2003), p.2). From an ethical perspective, computerizing patients' medical records must respect three of the most widely accepted principles of medical ethics: patient's autonomy, beneficence/non-maleficence and privacy and confidentiality.

The patient -- and not the hospital - is the owner of his medical records. Autonomous patients will argue that they the rightful owners of the intimate information contained in the EHRs. Conversely, individual health care providers and hospitals might argue for ownership of this information. hese obvious conflicts between economic and personal value, professional and patient autonomy, and business interest must be rectified before introducing EHRs (Mercuri, John J. (15 January 2010), p. 1.

The integrated data storage of an HER system also creates several potential harms as described by Mandl, Szolovits, and Kohane (3 February 2001, p. 1): Potential risks for confidentiality and privacy of patient data. Such concerns seem justified when one considers that, under current laws and practices, identifiable medical data are routinely shared with insurance companies, government, researchers, employers, state bureaus of vital statistics, pharmacy benefit managers (companies that track doctors' drug prescriptions), local retail pharmacies, and others. Medical records contain some of the most sensitive information about an individual.

The confidentiality of a patient's medical information is sacred in the healthcare profession. Unauthorized disclosure of such information result in anything from minor embarrassment to the loss of insurance or employment (Mercuri (15 January 2010). Patients therefore should have a right to decide who can examine and alter what part of their electronic medical records (Mandl, D.K. & Szolovits, P. & Kohane, I.S. (3 February 2001, p. 3). No matter how sophisticated security systems become, people will always manage to defeat them (Mandl & Szolovits & Kohane ibid).

One of the most difficult issues for a computerized medical records system's officer is to make sure that secure authentication tools, such as voice identification and/or so called "strong identification" tools are part of the system. Unlike most industries where a single login gets you complete access to applications and databases, health care systems require levels of authentication. For example, not everyone within a clinical institution has the authority or privilege to write a prescription.

A good electronic health record (EHR) implementation will have authentication levels based on roles so only an authorized physician can write a prescription. This means that when physicians log into an EMR their authentication provides them access to a restricted area of code that allows the processing of a prescription. That is what is sometimes referred to as "role-based authentication." Recommend how you would change the structure, governance, culture or focus on social responsibility to prevent this situation in the future.

I would recommend the following measures to create changes in the structure, governance and medical/hospital culture to ease the implementation of an electronic health recording system: The HER system must be fast, intuitive and easy to use for the physician. They should be built with well-designed hardware and software (Mercuri ibid, p. 1). If training is required it should be as minimal as possible in order to prevent.