Accurate pediatric documentation is not only essential for effective care and treatment for the child, but also plays a significant role in ensuring patient safety. A UK based study identified different types of pediatric safety incidents and found documentation-related errors among the most frequently cited contributory factors to patient harm. The family practice patient safety reports from a national UK repository between April 2003 and June 2012 were evaluated as part of a study and 1788 incident reports involving patients younger than 18 years were found. Out of these reports, 763 pointed out instances in which children were harmed, including nine reports of severe harm and eight reports of death.
The study published in Pediatrics, the official Journal of the American Academy of Pediatrics identified four key safety incident types within the reports such as:
- 34 reports highlighted delayed diagnosis and insufficient assessment that resulted in harmful outcomes with four deaths and 14 cases of moderate to severe harm
- 57 reports pointed out treatment and procedure-related incidents that resulted in harmful outcomes related to incorrect treatment decisions, especially during the treatment of patients with asthma or diabetes
- Referral-related incidents were highlighted in 66 reports with the most harmful outcomes related to the failure to refer children with developmental delays, acutely unwell children, or those with child protection concerns
- There were medication-related incident reports as well. The cause of most harmful outcomes in this regard was medication overdose resulting from inappropriate dispensing or prescribing
The authors found inaccurate medical records as one of the primary causes for patient harm. The other causes were resource issues (staffing, staff cognitive issues), and clinical skills errors (inadequate patient assessment). They suggest that this information can be used to improve patient safety and the recommended improvements include – mandatory pediatrics training for all family physicians, using electronic tools for diagnosis, management and referral decision-making and using technological adjuncts such as barcode scanning to reduce medication errors.
While responding to these findings, the president of the American Academy of Family Physicians noted that pediatric training is already a requirement in family medicine residency education in the United States. The transition to team-based care, and the use of electronic records and other patient-centered protocols aimed at enhancing quality of care and patient satisfaction are also improving the communication that can reduce medical errors.
However, there are drawbacks with electronic health records such as limitations to narrative description and the risk of copy – paste errors. Narrative description is essential to assess complex cases properly and provide appropriate treatment. Though copy pasting data within EHR can save physicians valuable time, they may overlook the mistakes within the data. This would compromise the accuracy of data in the medical records and drastically affect patient safety. EMR transcription wherein professional transcriptionists transcribe physicians’ dictations and enter the transcribed data into appropriate EMR fields is the best option to ensure the quality and accuracy of medical records.