Risk Management Tools & Resources

 


Copy and Paste: The EHR Documentation Gremlin

The practice of copy and paste — also called cut and paste, cloning, and carrying forward — is one of the most common and problematic documentation issues associated with electronic health records (EHRs). Copy and paste refers to electronically lifting information from a previous entry in a patient's record and placing it in the current entry. It also refers to copying information from one patient record to paste into another, such as through the use of boilerplate language. Automated functions within EHR systems facilitate copy and paste because of the ease with which users can grab and move content.

A survey done by the Medical Professional Liability Association (formerly PIAA) identifies copy and paste as the leading trend in EHR-related malpractice allegations, and a claims data analysis facilitated by CRICO Strategies also points to copy and paste as a top user error contributing to malpractice lawsuits.1

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CASE STUDY: Improper Management of Bariatric Surgery Patient Leads to Suboptimal Outcome

A patient underwent laparoscopic Roux-en-Y gastric bypass. During the immediate postoperative days, the patient experienced tachycardia and significant abdominal pain. An abdominal computed tomography (CT) scan revealed fluid in the abdomen, but the results were not immediately relayed to the surgeon.

Over the next 2 days, the patient's condition deteriorated, but neither the nursing staff nor the lab directly notified the surgeon about the critical CT scan results. Ultimately, the patient required surgery after developing respiratory distress, metabolic acidosis, septic shock, and acute renal failure.

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Bariatric Surgery Malpractice Allegations: What Claims Data Show, and Ways to Reduce Risk

Obesity is a well-known health concern in the United States. Often referred to as an epidemic, obesity affects about 36 percent of U.S. adults — more than double the number affected just 30 years ago.1 Bariatric surgery has emerged as an effective treatment option for many individuals who suffer from obesity, and the number of these procedures has increased over the years.

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CASE STUDY: Failure to Diagnose Pulmonary Embolism Results in Patient's Untimely Death

The patient was a male in his late twenties who suffered from obesity, asthma, high blood pressure, and Crohn's disease. He also had a recent history of surgical repair for a femur fracture. The patient visited his regular family medicine practitioner in October and was treated for rhinitis and sinusitis. His pulse oximetry reading at the time was 99 percent.

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Close Encounters of the Diagnostic Kind: Improving Provider–Patient Communication During the Diagnostic Process

The model of the diagnostic team, proposed in the Institute of Medicine's (IOM's) pivotal report Improving Diagnosis in Health Care, relies strongly on close collaboration with patients/families as part of the diagnostic process. In its recommendation for implementing a team approach, the IOM notes "Health care professionals and organizations are responsible for creating environments in which patients and their families can learn about and engage in the diagnostic process and provide feedback about their experience."1

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Safety in Numbers: Improving Diagnosis Through Teamwork

In recent years, numerous groups and individuals — including advocacy groups, researchers, healthcare providers, and others — have raised awareness and increased understanding about diagnostic errors, drawing attention to the profound effect that these errors have on patients, families, and clinicians.

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Data Insight: Opioid Treatment — Liability Risks in the Office Setting

It is nearly impossible to read or watch the news without mention of the opioid crisis. From patient addiction to death from overdosing, opioid abuse can have tragic outcomes. Further, when these unfortunate events are related to medical care, they can result in malpractice allegations against healthcare providers and organizations.

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Tips for Presenting a Patient With a Pain Management Contract

Pain management contracting is one strategy that healthcare providers can employ to help manage the risks associated with treating patients who take opioids. A pain management contract is a type of behavior contract, which is an agreement between a patient and healthcare provider or organization that defines expectations related to behavior, conduct, communication, and/or treatment. Using a pain management contract can help set standards and expectations in relation to a patient's care, the provider–patient relationship, and appropriate use of opioid therapy.

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