Data Insight: The Role of Documentation in Inpatient Surgical Treatment Malpractice Claims

Accurate, clear, and timely documentation of the clinical progression of patients is critically important in both acute and ambulatory care. Yet, documentation continues to represent an area of risk.

An analysis of 10 years of MedPro closed claims history shows that documentation issues consistently are in the top five risk factors associated with inpatient claims that have clinically severe outcomes (i.e., permanent disability or death).

Tips for Amending Electronic Health Records

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.

Because the majority of healthcare organizations have transitioned to electronic health records (EHRs) in the last decade, policies and procedures for amending records should reflect that change. In principle, many of the same standards for amending paper records apply to EHRs, such as not obscuring the original documentation, making timely corrections, and signing all entries. What differs in EHRs is the interface (including how the information is displayed and recorded), as well as the ability of the system to track user actions through metadata and audit trails.

The Role of Documentation in Diagnosis-Related Malpractice Allegations

Allegations 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.

MedPro Group's closed claims data from 2007 to 2016 show that documentation issues occur in almost 1 in 5 diagnosis-related claims. These issues generally fall into three categories: (1) insufficient/lack of documentation, (2) content, and (3) mechanics.

Strategies for Reducing Polypharmacy in Senior Care

Polypharmacy is a serious concern among adults, and especially among seniors. Although polypharmacy is preventable, it is a significant contributor to morbidity and mortality.¹ Polypharmacy is generally defined as taking multiple medications or more medications than are medically necessary (including over-the-counter drugs and supplements). A 2016 study showed that 36 percent of community-dwelling older adults (ages 62-85 years) were taking five or more prescription medications in 2010 to 2011 — up from 31 percent in 2005 to 2006.

Case Study: Patient's Health Deteriorates in the Absence of Proper Pressure Injury Care

The patient in this case study was a male in his mid-eighties who had a history of prostate and bladder cancer leading to bone metastasis. Following a hospital stay, he was transferred to a long-term care/rehabilitation facility. When the patient arrived at the facility, the admissions nurse documented that he had a Stage 4 sacral pressure injury.

The patient subsequently developed several other Stage 2 and Stage 3 pressure injuries on the buttocks. Daily skin assessments were not completed, and facility nurses never documented any wound assessment or patient response to wound treatment. Within 2 weeks, the patient developed a C. difficile infection, and the sacral pressure injury progressed to involve the patient's bone.

Case Study: Patient Falls and Dies After Multiple Missteps in Care

The patient was a female in her late sixties who was admitted to a long-term care facility following a craniotomy procedure for craniopharyngioma. The patient had multiple medical issues at the time she was admitted, including postoperative deep vein thrombosis (for which she was receiving anticoagulation therapy) and a ventriculoperitoneal (VP) shunt.

Case Study: Multiple Lapses Result in Patient Fall and Injury

A male in his mid-sixties presented to his local emergency department (ED) with complaints of shortness of breath and chest pain. He had a history of chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). The patient was admitted to the hospital for exacerbation of COPD symptoms and atypical chest pain.

Reducing Medication Prescribing and Administration Errors: Strategies for Critical Access Hospitals

Prescribing and administering medications are complex processes, particularly because of the volume of medication orders in hospitals and the increasing number of prescription medications on the market. The Institute of Medicine (IOM) notes that although errors are common throughout the medication process, they are most common at the prescription and administration stages.¹