Question

Elizabeth Mullins was a patient in Mercy Hospital. During her hospital stay, a medication administration error occurred, resulting in permanent harm. She sued Mercy Hospital, the hospitalist, and several members of the nursing staff and the pharmacy staff. During the discovery process, her attorney obtained her authorization and requested a copy of her health record. Per its procedure, the HIM department at Mercy Hospital produced a paper copy from the patient’s electronic health record. Elizabeth’s attorney then requested to review her electronic health record on the EHR system. He was granted access after Elizabeth signed an authorization and a time was arranged for him to review the EHR in the HIM department. The attorney reviewed the paper record and found that the progress notes were voluminous and identical from one day to the next, reflecting no change in Elizabeth’s status. This made him angry because the copied record was quite expensive, yet information was redundant and appeared not to have been updated from one day to the next. Further, in three progress notes, he found references to a patient named “Theresa,” who had a different diagnosis. When the attorney compared the paper record and the record that he reviewed on the screen, they looked very dissimilar (although references to Theresa were also present in the electronic record). He also was unable to locate any e-mails or text messages in either the paper or electronic version of the record, although Elizabeth produced several between her and her physician from her mobile phone. When the attorney requested a list of the components of Mercy Hospital’s legal health record policy, he found that its list of components included e-mail and text communications between providers and patients, as well as those among providers.

What legal problems will Mercy Hospital encounter regarding its legal health record?

What operational problems does Mercy Hospital need to address regarding its legal health record?

Who should be included on a team to address the previously identified problems?

Answer 1

A legal health record in every healthcare institution provides the basic information regarding every aspects of the standard of care provided to them. Therefore its very important to update such records timely and to maintain the continuity of care.

A) The legal health record of Mercy Hospital has violated certain international patient safety goals. At first a proper patient identification is not done. The hospital will be blamed for wrong identification of patient. Secondly the medication error resulting in permanent harm to patient is categorised under sentinel events, for which the hospital will be answerable. Thirdly, incomplete documention and updation of patient status.

B) Inadequate training of the staff in case of medication management and documentation needs to be addressed. Wrong identification of patient and breech in following the rights of drug administration can also be included in the list of operational problems of the hospital. All the staff should undergo orientation classes and inservice education programs. Medication Management and Use classes should be taken prior to medicating any patient.

C) Team members should include

• Nursing staff
• Charge Nurse
• Nursing Supervisor
• Pharmacist
• Doctor