Risk Management Tools & Resources


Case Study: Oversight in Electronic Health Record Causes a Delay in Ovarian Cancer Diagnosis

Laura M. Cascella, MA, CPHRM


Electronic health records (EHRs) have transformed the ways in which healthcare providers work and communicate. These systems have been both extolled and criticized over the years as their use in hospitals, healthcare practices, and other healthcare facilities has become ubiquitous.

Like many current health technologies, EHR systems represent a complex dichotomy — they can be both beneficial and problematic, as illustrated in this case study.

Case Details

The patient was in her early fifties and had a strong family history of breast cancer. Her gynecologist, Dr. B, ordered BRCA1 and BRCA2 analysis. The patient’s results were received from the laboratory and scanned into the OB/GYN practice’s EHR system.

The top portion of the report indicated a positive finding for a potentially harmful mutation. This information was included in large, capitalized, bold lettering. In the lower portion of the report, however, a box with small print indicated no mutations were detected in the BRCA1 (5-site rearrangement panel) and BRCA2 sequencing. Dr. B believed that when he reviewed the report in the EHR, he scrolled down too far initially and missed seeing the top of the report. Thus, the patient was not informed about the positive finding.

Eighteen months later, the patient was diagnosed with Stage III ovarian cancer. She subsequently filed a lawsuit against Dr. B. Experts who testified in the case believed that the cancer was not present at the time of BRCA testing. They felt that if the patient had undergone bilateral salpingo-oophorectomy at that time, her risk of primary peritoneal cancer would have been around 1 percent. Ultimately, the case was settled against Dr. B, with both payment and defense costs in the high range.


Almost all hospitals and the majority of office-based physician practices in the United States use EHR systems.1 Although doctors and other healthcare professionals have seen the benefits of these systems, they also have noted numerous challenges with EHR functions, capabilities, and workflows.

EHRs also have introduced a new dynamic in relation to malpractice liability. Contributing factors in EHR-related litigation include problems with documentation practices, system usability, system conversion, metadata, record format, vendor support, training, and more.2

In this particular case, a simple oversight of critical information on a report scanned into the OB/GYN practice’s EHR system led to a diagnostic error and a poor patient outcome. Of note, the OB/GYN practice in this case was implementing a new EHR system at the time that this error occurred. Dr. B’s lack of familiarity with the system may have contributed to him missing the critical information on the lab results.

The process of implementing or upgrading an EHR system is vulnerable to errors because of the changes that occur, such as transfer of data, workflow modifications, and new interfaces. Implementing or upgrading an EHR system requires thorough research, careful planning, and ongoing assessment and adjustment once the system is in place.

To minimize the risks associated with implementation, healthcare practices should develop clear policies for transitioning data between systems and for reconciling information, so as not to misplace data or overlook critical health information. Further, careful evaluation and an open dialogue with healthcare providers and staff about workflow processes may help identify potential issues early and facilitate the development of effective strategies.

Additional steps that healthcare practices can take to reduce the risk of errors, improve patient safety, and reduce liability exposure when implementing an EHR system include:

  • Asking healthcare providers and staff members who will be using the EHR system to participate in initial research and planning activities related to EHR acquisition and implementation
  • Developing a policy for how records and reports should be displayed in the EHR system as well as expectations for thorough review of patient records and test/consultative reports
  • Seeking input from providers and staff about developing policies and workflow procedures that align with the new system
  • Ensuring that the new EHR system supports the healthcare practice’s patient tracking procedures, and reviewing whether alerts or other features are available to help facilitate communication of critical findings
  • Supporting healthcare providers and staff throughout the implementation phase by including them in the decision-making process, maintaining transparent communication, and establishing firm expectations related to EHR use
  • Providing training and education during implementation and after to help staff acclimate to the new system, recognize potential process or system problems, and work toward achievable solutions
  • Being realistic about the cost (both in external resources and staff time) that it will take to implement the new system

In Summary

Like other technologies, EHR systems aren’t without risks. Changes in workflow, poor understanding of the system and its capabilities, user and system errors, and lack of defined protocols can all lead to process breakdowns and potentially harmful mistakes.

Awareness of the potential risks that EHRs present can help healthcare providers and staff proactively counter them through ongoing staff training, workflow evaluation, and development of comprehensive policies and procedures.


1 HealthLeaders Media News. (2016, June 3). Only 4% of hospitals don’t use EHRs. Retrieved from www.healthleadersmedia.com/innovation/only-4-hospitals-dont-use-ehrs; Office of the National Coordinator for Health Information Technology. (2019, January). Office-based physician electronic health record adoption. Health IT Quick-Stat #50. Retrieved from https://www.healthit.gov/data/quickstats/office-based-physician-electronic-health-record-adoption

2 PIAA. (2015, January). Part 1 of 2: Electronic health records and a summary analysis on the 2012 PIAA EHR Survey. Research Notes, 1(1), 3; MedPro Group. (2018). Claims involving issues related to electronic health records. Retrieved from www.medpro.com/documents/10502/5086245/Claims+Involving+EHR-Related+Issues.pdf

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