Electronic Records and Patient Safety

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Guidelines have been put in place for healthcare professionals and staff in medical facilities that require that standards are followed closely. These guidelines are to provide proper treatment and avoid medical malpractice as much as possible. One standard is to provide safety of medical records and privacy. A physician may be held liable for breaching a patientís confidentiality.

Patient Rights

Medical privacy is granted to patients and includes the safeguard of personal information, medical records, healthcare history and other documentation by healthcare staff. This information is not to be disclosed to anyone other than those the individual has assigned. Typically this person or persons becomes the medical proxy. The confidential records are also protected by the Health Insurance Portability and Accountability Act under federal policy. The key goal of the act it to provide easier access to health insurance, protect the privacy and safety of medical information and assist the healthcare business regulate organizational costs. Violation of privacy occurs when a healthcare professional or staff disclose the patientís medical information to anyone other than the individualís approved persons or other entities that are allowed access to the information according to law. The staff can be held liable for the release of the information.

Technological Age

New technological advances are entering the marketplace, medical fields and home life that help streamline information. However, it has become much easier to release information by accident with email, networked computers, databases and the internet inside and outside the medical facility. Social media allows for instant communication with the outside world, and smartphones connect patients with others by a touch of fingers. The risks of disclosing records has become much higher than ever before.

Many physicians have contacted the American Medical Association to explain that they believe the move to electronic record keeping is less efficient, compromises patient safety and may cause accidental release of information. Systems are required to be updated in many facilities to implement the new electronic system.


Medical errors may occur in various aspects associated with electronic records. When the fields are self-populating or suggestive, many may record incorrect data. Cutting and pasting between records or different patients may cause even further issues. There is a higher likelihood of losing data or a glitch affecting the accuracy of data. Computer errors and failures may become a fatal factor for some individuals.

The success of this electronic system has been evaluated by about 10,000 healthcare professionals. One study found that 15 percent of them asserted the systems may have led to severe errors. Computer programs sometimes guide providers to prescribe incorrect medicine. Some lab orders were issued when not necessary, and tests were ordered when they were not needed.

Greater Dangers

Some medical experts explain they are spending more time inputting data, causing them to have minimal time to examine or speak to the patient. Because this is occurring for some physicians, the potential risk of misdiagnosis has increased. Discussing symptoms and issues with the individual often reveals more information that is needed. Shorter visits and longer wait times have been observed by many patients. They state their doctors are not paying attention to them during the visit and the physician is distracted.

Medical malpractice runs a much greater risk of occurring when the healthcare practitioners are too focused on faulty, baffling or disrupting computer software. This may further lead to incorrect diagnosis, medication errors, unnecessary tests or treatment for the wrong person or wrong ailment.

Other Problems

With the availability of cell phones, social media, database issues and internet inside the healthcare facility, distractions are abundant. Injury to patients may occur when these electronic devices are in the operating room or distracting a surgeon before they initiate surgical procedures. If software is malfunctioning, operations, medicine and even treatment may harm the patient if they are incorrect or in the wrong dose.

The potential to injure a person with the sharing of their medical visit or experience is far greater with the use of social media and smartphones in the healthcare facility. It only takes one picture and an explanation to violate confidentiality. This reveals why the person was in the hospital and may also show what they look like after the procedure.

Contact a Lawyer

For any suspected or potential breaches of confidentiality, a patient should contact a lawyer. A lawyer well-versed in the healthcare arena is necessary, but documentation is paramount to building a case. A lawyer can help pursue compensation for privacy breaches or medical malpractice.

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Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.

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