Altering documentation in patient records can have serious consequences, including allegations of fraud and professional misconduct — and it also can make malpractice claims difficult to defend. Yet, mistakes happen and situations undoubtedly will occur that require healthcare providers to make corrections, addendums, or late entries in patient records.
Read moreAllegations associated with diagnostic errors — i.e., wrong diagnoses, delayed diagnoses, and missed diagnoses — are a top cause of malpractice lawsuits. A number of risk factors can lead to diagnostic errors, including issues related to documentation of clinical care.
Read moreElectronic 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.
Read moreDocumentation is paramount in healthcare delivery because it memorializes patient care, facilitates communication among caregivers, forms the basis for coding and billing, provides data pertinent to quality improvement, and may provide information that is critical to the defense of a legal action. Documentation also serves a crucial role in the disclosure of unanticipated outcomes, such as medical errors, medical mismanagement, system errors, or other unforeseen situations that lead to patient harm.
Read moreWorking to minimize medication errors and adverse drug events (ADEs) is a worthwhile goal for healthcare practices. Eliminating all errors and ADEs, however, is unlikely due to the fast-paced nature of the healthcare environment, the numerous demands providers face, and the staggering number of medications on the market.
Read moreObstructive sleep apnea (OSA) is an insidious condition that can result in significant healthcare-acquired injuries if it is not properly recognized and treated. This case illustrates what can happen when a patient's treating physicians do not address and adequately communicate information about OSA to other members of the healthcare team — in this case, the surgery recovery staff.
Read moreThe patient, a female in her mid-thirties, presented to a dermatology practice for consultation regarding hair removal on both sides of her chin. The patient met with an esthetician employed by the practice, who requested that the patient fill out a skin care questionnaire. The patient complied, and described her skin's complexion as olive and noted that she rarely burns.
Read moreClaims involving improper credentialing often coincide with allegations of improper and inadequate training. This case examines a failed resuscitation effort at an ambulatory surgery center (ASC) in which credentialing issues, deficient emergency response procedures, and lack of staff training all contributed to a tragic outcome.
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