Electronic medical records (EMRs) are now a foundational component of modern healthcare in Alberta. Hospitals, clinics, and long-term care facilities rely heavily on digital charting systems to document patient histories, record test results, track medications, and coordinate care among multiple providers. In theory, EMRs are designed to improve efficiency, reduce errors, and enhance patient safety.
In practice, however, electronic medical records can introduce new risks. Charting errors, data omissions, auto-populated inaccuracies, and miscommunications embedded in EMRs have become a growing source of patient harm. When healthcare providers rely on incorrect or incomplete electronic records, critical medical decisions may be based on faulty information, sometimes with devastating consequences.
The Role of Electronic Medical Records in Alberta Healthcare
Electronic medical records are intended to serve as a comprehensive, real-time account of a patient’s medical care. They often include diagnostic test results, physician and nursing notes, medication orders, allergy warnings, consult requests, and discharge instructions. In many cases, EMRs replace handwritten charts entirely.
Alberta’s healthcare system relies on integrated electronic systems to facilitate communication between hospitals, physicians, specialists, and allied healthcare professionals. When used properly, EMRs can enhance continuity of care and reduce duplication of testing. However, these systems are only as reliable as the information entered into them and the manner in which they are reviewed and interpreted.
Errors within electronic records can propagate quickly. A single inaccurate entry may be copied, forwarded, or relied upon by multiple providers across different settings, magnifying the risk of harm.
Common Types of Electronic Medical Record Errors
Electronic charting errors can take many forms. Some are subtle and difficult to detect, while others are obvious but overlooked in fast-paced clinical environments. The most common types of EMR-related errors include inaccurate data entry, missing documentation, and inappropriate reliance on automated features.
Copy-and-paste functions, for example, are widely used to save time. While convenient, they can perpetuate outdated or incorrect information. A physician may unknowingly replicate a prior note that contains an error, leading subsequent providers to rely on false assumptions about a patient’s condition.
Auto-populated fields can also introduce inaccuracies. EMR templates may pre-fill normal findings or default responses, which are sometimes left unchanged even when abnormal findings are present. This can result in charts that suggest a patient was stable or improving when, in reality, their condition was deteriorating.
Another frequent issue involves delayed or missing test results. Laboratory findings or imaging reports may be uploaded to an EMR but not reviewed promptly, or they may be misfiled within the system. When abnormal results are overlooked, opportunities for timely diagnosis and treatment may be lost.
How Charting Errors Translate Into Patient Harm
Electronic medical record errors are not merely administrative issues. They can directly influence clinical decision-making and patient outcomes. When a healthcare provider relies on incorrect information, the consequences can be severe.
Medication errors are a common example. Inaccurate medication lists, undocumented allergies, or failure to reconcile medications during admission or discharge can lead to dangerous drug interactions or overdoses. Patients may receive medications they should never have been prescribed or may be deprived of essential treatments.
Diagnostic errors also frequently stem from charting mistakes. If symptoms are misdocumented, prior test results are missing, or relevant medical history is omitted, physicians may pursue incorrect diagnoses or fail to recognize serious conditions. Delayed diagnoses of infections, strokes, cancers, and internal bleeding are often linked to incomplete or misleading medical records.
In surgical and post-operative settings, charting errors can obscure warning signs of complications. Failure to accurately document vital signs, pain levels, or changes in neurological status may result in delayed intervention and worsened outcomes.
Communication Breakdowns and Fragmented Care
Modern healthcare is highly collaborative. Patients are often treated by multiple providers across different departments and facilities. Electronic medical records are meant to facilitate seamless communication, but errors within those systems can instead create dangerous gaps in care.
When handovers occur, such as during shift changes or patient transfers, providers rely heavily on EMR documentation to understand a patient’s status and care plan. If critical information is missing or inaccurate, the incoming provider may not appreciate the urgency of a situation or may misunderstand prior clinical decisions.
Fragmented care increases the risk of charting errors being overlooked. Each provider may assume that someone else has reviewed test results, updated medication lists, or followed up on abnormal findings. In this environment, electronic records can create a false sense of security, masking serious omissions.
Alarm Fatigue and Overreliance on Digital Systems
Electronic medical records often integrate with monitoring systems that generate alerts for abnormal vital signs, medication interactions, or test results. While these alerts are intended to enhance safety, excessive notifications can lead to alarm fatigue.
When providers are inundated with alerts, many of which may be low-priority or clinically irrelevant, they may begin to dismiss or overlook warnings altogether. Critical alerts may be ignored or delayed, particularly in high-pressure settings such as emergency departments or intensive care units.
Overreliance on electronic prompts can also diminish clinical judgment. Providers may assume that the absence of an alert means there is no problem, even when clinical signs suggest otherwise. This reliance on technology, rather than careful assessment and verification, can contribute to preventable harm.
Electronic Charting and the Standard of Care
The existence of an electronic medical record does not alter the legal standard of care owed to patients. Healthcare providers remain responsible for exercising reasonable skill, judgment, and diligence, regardless of whether documentation is handwritten or digital.
In medical malpractice cases, EMRs are often central pieces of evidence. Courts and experts examine whether records were accurate, complete, and timely, and whether providers appropriately reviewed and acted upon the information available to them.
Charting errors may constitute negligence when they fall below the standard of care expected of a reasonably competent healthcare professional in similar circumstances. This may include failing to document critical information, entering misleading data, or relying on inaccurate records without verification.
Importantly, the presence of an EMR does not excuse a provider from independently assessing a patient. Blind reliance on electronic documentation, particularly when clinical signs suggest otherwise, may be viewed as a breach of professional obligations.
Lost Test Results and Missed Follow-Ups
One of the most litigated categories of EMR-related errors involves lost or unaddressed test results. Diagnostic tests may be ordered appropriately, but the results are never reviewed, communicated, or acted upon.
Electronic systems can obscure responsibility for follow-up. Results may be routed to multiple providers, leading each to assume someone else will take action. In other cases, results may be filed in obscure sections of the EMR or buried among numerous entries.
Missed follow-ups are particularly dangerous when abnormal results suggest serious conditions such as cancer, infection, or internal injury. Delays in diagnosis can allow diseases to progress to more advanced stages, reducing treatment options and survival rates.
Documentation After Adverse Events
Accurate documentation following an adverse event is crucial for ensuring patient safety and maintaining legal accountability. However, EMRs may be altered, supplemented, or corrected after the fact in ways that raise serious concerns.
While legitimate corrections are permitted, retroactive charting that obscures or minimizes an adverse event can complicate patient care and undermine trust. In litigation, discrepancies in timestamps, metadata, and audit trails may reveal inconsistencies between what occurred and what was documented.
Courts scrutinize electronic records carefully, particularly when documentation appears self-serving or incomplete. Inconsistent entries, late additions, or unexplained deletions can weaken a defence and support allegations of negligence.
Proving Medical Negligence Involving EMR Errors
Medical malpractice claims based on electronic charting errors are complex. It is not enough to show that a mistake occurred; plaintiffs must establish that the error caused or contributed to patient harm.
This often requires detailed expert evidence. Medical experts assess whether the charting error deviated from accepted standards and whether proper documentation or review would likely have altered the patient’s outcome. Technical experts may also be required to analyze EMR systems, audit trails, and workflows.
Causation is frequently the most contested issue. Defendants may argue that the harm would have occurred regardless of the documentation error. A thorough investigation and early legal analysis are essential to building a strong claim.
Why EMR-Related Malpractice Claims Are Increasing
As electronic medical records become more entrenched in healthcare, EMR-related malpractice claims are likely to increase. Digital systems create detailed, permanent records that can expose inconsistencies, omissions, and deviations from protocols.
At the same time, the complexity of these systems introduces new opportunities for error. Providers must navigate evolving software, frequent updates, and competing documentation demands, often under significant time pressure.
Patients, meanwhile, may be unaware that charting errors played a role in their injury until medical records are carefully reviewed. Legal claims often arise months or years later, once the connection between documentation failures and patient harm becomes clear.
Technology Does Not Eliminate Responsibility
Electronic medical records are powerful tools, but they do not eliminate the human responsibility at the core of healthcare. Accurate documentation, careful review, and sound clinical judgment remain essential to patient safety.
When charting mistakes, system failures, or overreliance on digital records lead to serious harm, the consequences can be life-altering. Medical malpractice law exists to address these failures, provide compensation to injured patients, and encourage safer practices.
As healthcare continues to evolve, understanding the legal implications of electronic medical record errors will remain a critical issue for patients, providers, and the justice system alike.
Cuming & Gillespie LLP: Providing Modern Advocacy in Medical Malpractice Claims in Calgary
If you or a loved one has suffered serious harm due to a medical error, incomplete documentation, or reliance on inaccurate electronic medical records, you may have legal options. Medical malpractice claims involving charting errors are complex and highly technical, often requiring careful review of medical records and expert evidence. Speak with the experienced medical malpractice lawyers at Cuming & Gillespie LLP to understand whether a charting error contributed to your injury and what steps may be available to protect your rights. To book a complimentary consultation, please contact us online or call (403) 571-0555.