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"Sloppy" Copy and Paste Errors Exist in Many Medical Records

Electronic health records or "EHRs" have taken over American hospitals in the last ten years. Proponents hoped that using electronic documentation would improve patient safety - all caregivers would have immediate online access to all of the patient's medical information in the same place.

According to a recent study, however, EHRs involve at least one big risk that hard copy medical records did not: "sloppy and paste." "Sloppy and paste" refers to the practice of copying a body of existing text from one record and pasting it into an updated record. If the doctor or nurse does not carefully review the text to be sure that it is still accurate and relevant, outdated information can appear in a later entry.

This leads to confusion and potentially serious mistakes on the part of other caregivers who base decisions on the mistakenly copied text in the future. Medication errors and overdoses are one particularly dangerous risk.

New research looked at this problem by using software to search EHRs for bodies of identical text in progress notes. The study found that between 74 and 82 percent of progress notes consisted of at least 20 percent copied information. If these numbers are accurate, they would represent an improvement from another study in 2010. That study found that copy-and-pasted text made up 54 percent of surveyed progress notes.

This indicates a big patient safety problem. With awareness of this issue growing, hospitals may have an obligation to take more meaningful steps to prevent dangerous "sloppy and paste" errors.

Source: American Medical News, "EHRs: 'Sloppy and paste' endures despite patient safety risk," Kevin B. O'Reilly, Feb. 4, 2013

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