Paper-based errors

I recently heard about several medical errors that were caused by lack of information due to paper-based records:

  • Wrong patient sent to theatre due to changes in the theatre list not being updated.  The surgeon was working off an old list, and the anaesthetist and theatre staff a newer, updated version.  This would be overcome by utilising a ‘latest and greatest’ approach in an electronic system, i.e. the most recent change becomes the current version, and all previous changes are automatically updated
  • Patient received the wrong resuscitaiton drugs during a cardic arrest due to the doctors being handed another patient’s paper record.  This is a failure of patient identification and fragmentation of records.
  • Patient had the wrong operation due to the paper theatre list having different information to the paper consent form.  This is an example of fragmentation of records that would be overcome by an integrated electronic record
  • 10% of hospital paper-based prescriptions contain errors, and up to 2% are potentially life-threatening

These are all real-life and recent incidents.  Patients continue to be harmed by antiquated systems that are unreliable, and frankly, dangerous.  Many of thsese incidents would be overcome by the integrated use of electronic systems.  Doctors must see the introduction of electronic systems as a essential step towards safer patient care.