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Medical Record Errors: Even Minor Mistakes Can Have Major Consequences

doctor looking at patient records

When it comes to medical malpractice, most people assume the worst. That’s because medical mistakes made by doctors, specialists, nurses, and other health care providers can have disastrous consequences for victims and their families. While we may hear of these tragedies when major incidents make the news, not all forms of malpractice involve egregious errors such as leaving medical tools inside a patient’s body or harming newborns with archaic-sounding tools like forceps or vacuum extractors. Many result from minor mistakes in medical records – and they can cause some the most severe and profound consequences.

Among the hundreds of thousands of injuries caused by medical errors and the roughly 250,000 deaths they result in each year (making them the third leading cause of death in the U.S.), many medical errors harm patients in less-than-obvious ways. This can include illnesses that are not identified or are misdiagnosed, and which can progress under the radar without treatment and intervention. These types of scenarios are indicative of much larger problems within health care, especially in terms of patient records and documentation.

Medical records are an inherent part of treatment, and have been around for as long as humans have been practicing medicine. Whether they’re for the purpose of billing, gaining historical insight into a patient’s health, or for coordinated care and patient hand-offs, medical records (electronic or otherwise) are vitally important to patient health. Unfortunately, that also means they can play a big role in causing or contributing to preventable injuries and deaths. That’s due to not only initial mistakes, but also the fact that they are often unaddressed and repeated, leading to errors in diagnosis and treatment. In a health care industry where coordinated care and treatment from multiple doctors is common, mistakes can be perpetuated by each provider who does not want to start from the beginning. That first mistake can multiple countless times and create massive problems.

Common Medical Record Errors

While there may be a number of reasons why errors in medical records can occur – from the complexity of health care recordkeeping, new technology, and human errors to providers being short on time or overly focused on billing, regulatory oversight, and finances – there is no understating their potential for causing preventable harm. Below are just a few examples of how medical record errors can have major consequences:

  • Errors as seemingly minor as misspelling can have unintended consequences, such as misleading future health care providers when treating patients, impacting how a practice codes and bills a service, or even confuse patients when reviewing records.
  • Errors made in dictating or writing medical notes, including mistakes that discuss injuries or conditions affecting the incorrect side of the body or an incorrect body part – such as records that state issues with the left leg rather than the right. This can result in a range of consequences involving care, and in the most serious cases may result in wrong-site surgeries and other surgical errors.
  • Errors regarding patient health history (including genetics, known allergies, and family history of medical ailments) that may cause providers to fail in exploring potential issues or conditions, failures to diagnose a condition that should have been diagnosed, or providing treatment that could exacerbate existing conditions and cause patients further harm.
  • Errors in documentation of medications, which can result in medication errors, adverse drug reactions, dosage errors, and injuries.
  • Misidentification of patients or errors in recordkeeping that leads to patients receiving care or treatment that should have been provided to another patient, or not receiving the treatment they need.
  • Errors in documentation and records transmitted between physicians, hospitals, labs and testing services, pharmacies, and other providers, which can result in oversight of diagnosable and treatable conditions, medication errors, and other adverse patient consequences.

When patients suffer injuries and illnesses they suspect were caused by medical malpractice, in-depth evaluations and medical record reviews become critical. At Levinson Axelrod, P.A., our New Jersey medical malpractice attorneys carefully review our clients’ medical records for any potential errors or red flags that may have contributed to their injuries and damages, and which can form the basis of evidence to be used in their lawsuits. Because even minor mistakes can have such serious consequences, meticulousness in these evaluations, as well as insight and experience, are crucial to protecting the rights of patients who were harmed by errors that should have been identified, or never have happened in the first place.

If you have questions about a potential medical malpractice case, medical record errors, and your rights as a victim, please do not hesitate to call (732) 440-3089 or contact us online for a free consultation. Levinson Axelrod, P.A. serves clients throughout New Jersey from multiple office locations, and handles a range of malpractice cases.

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