Inaccuracy in eye health records identified

A recent study conducted by researchers at the University of Michigan Kellogg Eye Centre looked at medication-related information contained in the electronic health records of patients treated for microbial keratitis between July 2015 and August 2018.Of the printed medication lists automatically generated from electronic health records, one-third of the 53 participants had at least one mismatch between medications discussed in clinician’s notes and those on the medication list.“Corneal infection is an important disease condition to study ophthalmic medication lists because the medications change rapidly,” Dr Maria Woodward, lead author on the study, said.“Because of the multiple clinic visits and frequent medication changes it is imperative to have strong verbal and written communication between providers and patients who are battling corneal infections.”{{quote-A:R-W:400-I:2-Q: Patients who rely on the after-visit summary may be at risk for avoidable medication errors -WHO:Maria Woodward, University of Michigan}}According to the researchers the errors occur when the healthcare provider communicates medication instructions to the patients. While instructions are communicated verbally, notes are also typed into the ‘free text’ section of a patient’s electronic health record. It was here that researchers identified the discrepancy.“This level of inconsistency is a red flag,” Woodward said.“Patients who rely on the after-visit summary may be at risk for avoidable medication errors that may affect their healing or experience medication toxicity.”To prevent errors, the researchers recommend a syst of double-documenting medication lists.“The same information must be entered into the clinician’s note and the formal medication list — two separate places,” Woodward said.“In a busy clinical setting, our top priority is communicating directly with the patient and answering their questions. We’re focused on clarifying the treatment plan and addressing concerns, so duplicating note taking does not rise to our primary mission.”The team suggests electronic heath record developers could create software solutions to ease the burden of clinical documentation.