Copy-Paste Use in EHRs: Safety Issues

The use of copy and paste functionality in electronic health records (EHRs) has introduced "unintended safety-related issues into the clinical environment,” according to a study by the U.S. National Institutes of Standards and Technology. Copy and paste, which is intended to help clinicians post information in patients’ records, can cause errors to be put into those records and then continued over time, the study says.

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NIST conducted the study in collaboration with patient safety organisation ECRI and the U.S. Army Medical Research and Material Command. Researchers interviewed physicians and nurses interacting with the military’s AHLTA EHR.

Copy and paste makes it easy for medical practitioners to reuse information in patient EHRs without having to retype the information. However, clinicians interviewed for the study had concerns about the integrity of information while using copy and paste and identified a high potential risk of entering wrong information in the wrong chart. A common error with copy and paste is that clinicians forget to review and edit all of the information they reproduce in records — and researchers identified "frequent interruptions in the clinical environment" as one of the major causes of this error. Another reason for this type of error is that many of the EHR systems used by clinicians do not have adequate editing capabilities.

Based on the findings, the researchers have made numerous recommendations to prevent users from inadvertently copying only part of the intended information. Other recommendations include:

• EHRs should be able to reconcile that copied information was read and edited by the provider.
• EHRs should be able to reconcile that copied information was read and edited by the provider.
• Copy and paste must not be permitted when entering data into a blood bank information system.
• Demographic information should never be copied but auto-populated in all interfaces in a patient chart.
• Copying of demographic data from one chart to another should be prohibited.
• Dates should never be copied and pasted.

Other recommendations cover specific functions for handling allergies, surgical notes, medication entry, discharge summary, and copying and pasting information from different departments and another patient’s electronic health record.

Source: Health Data Management
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