How Medical Record Errors Can Lead to Serious Patient Harm

When we consider medical care, we think of procedures, bandages, medical tools, and injections. A less obvious but tremendously important aspect of patient care is medical record-keeping.

While record-keeping occurs behind the scenes, it’s crucial to ensure safe and effective patient care. A medical record error, oversight, or omission can result in significant harm to a patient, including injury, worsening of a medical condition, catastrophic harm or even death. In the event a medical record has caused you harm, reach out to our medical malpractice attorneys in Chicago.

What Types of Medical Record Mistakes Lead to Serious Injuries?

A tremendous portion of patient care relies on accurate record-keeping. For example, a patient’s medical records should include their contact information, demographics, medical history, recent lab results, immunizations, medication lists, and any medical imaging results.

A mistake or oversight can lead to serious adverse outcomes. Common medical record errors include the following:

• Missing medical history
• Failure to update a patient’s medical history
• Incomplete or incorrect medication and dosage list
• Unrecorded medication allergies
• Missing test results
• Incomplete medical record transfers or hand-offs between providers
• Failure to remove completed medications from a patient’s record
• Transferring the wrong patient records or placing the one patient’s records into another patient’s written or electronic chart

Medical record errors often result from poor protocols, inadequate training, provider negligence, communication breakdowns, or software failures in a patient’s electronic health record.

Even when the record-keeping failure results from a software problem, the medical facility is ultimately responsible for ensuring the information is accurate, complete, and up-to-date.

Understanding Patient Harm Due to Medical Record Errors

When a patient’s medical record is missing crucial information or contains errors, oversights, or inaccuracies, the result can be disastrous for the patient. Some examples of harm caused to patients due to medical record mistakes include the following:

• A patient could be administered the wrong dosage of a medication, resulting in ineffectiveness or overdose
• Dangerous medication interactions
• A patient may be administered a drug to which they are allergic
• Wrong patient, wrong site, wrong surgeries may occur
• Misdiagnosis, missed diagnosis, or delayed diagnosis may occur, resulting in advanced disease and worsened prognosis
• Inappropriate treatment protocols occur
• A patient may die due to a preventable condition or error directly resulting from a mistake in their medical records

When a patient suffers harm due to a medical record error, the results could be devastating, including catastrophic harm or death. Medical record mistakes are a breach of a medical provider’s legal duty to treat a patient at the medical community’s accepted standard of care, leaving the at-fault party liable for damages.

Who Is Responsible for a Medical Record Error?

According to a medical research study, as many as 21% of patients discover errors in their medical records. Responsible parties, such as the following, could be held liable for the damages in these cases:

• The doctor
• The nursing staff
• A pharmacy
• Assisting staff members and administrators
• A hospital or medical facility

When a patient suffers significant harm from a medical record error, they have a right to recover compensation for the resulting damages, including additional medical expenses, lost earnings, pain and suffering, and catastrophic harm, such as disability, impairment, diminished quality of life, loss of limb or organ, or chronic pain.

If the medical record mistake causes a patient’s death, the family can recover compensation for their losses through a medical malpractice wrongful-death case.