Patient Safety: Lessons Learned
By Alexis Reeves, RN, MBA, CPHRM, CLNC, Director of Patient Safety Operations
When clinicians use copy and paste in the electronic medical record, there’s the potential for sharing erroneous or outdated information. The following article outlines recommended steps to make this time-saving practice safer.
To Copy and Paste or Not to Copy and Paste?
That is the question. In the fast-paced world of medicine, clinicians often create workarounds to manage demands for their time. One such workaround involves using the copy and paste function in the electronic medical record (EMR). But information technology intended to improve patient safety sometimes has unanticipated consequences, especially when its users create alternate ways to document than what was originally intended.
The practice of copy and paste has become the norm for documenting in the EMR. Although it can save time, there are risks associated with its use: copying and pasting inaccurate or outdated information; redundant information in the EMR, which makes it difficult to locate current information; and the inability to identify the source of the information, to name a few. In short, copy and paste can lead clinicians to inadvertently convey misinformation if they do not review it for accuracy. These copy and paste errors have been a factor in unnecessary treatments and/or procedures, and delays in diagnosis or appropriate treatment.
The National Patient Safety Foundation (NPSF) has offered the following recommendations for using copy and paste more safely.
Recommendation A:
Provide a mechanism to make copy and pasted material easily identifiable.
It is crucial for clinicians to be able to identify text that has been copied and pasted so they can more easily verify its accuracy and review it for needed edits. Use a split screen or format the copied material in italics.
Recommendation B:
Ensure that the origin of the copy and pasted material is readily available.
Clinicians need to be able to figure out fairly easily where the copied material originated, which helps verify its accuracy and appropriateness. One potential solution allows for source information about the copied material to “hover” over it when it is being accessed.
Recommendation C:
Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.
One of the benefits of copy and paste functionality is that it is a quick and efficient way to document complex information, especially if the information does not change much over time. To ensure that the function is used correctly, and that safety steps are not ignored, ongoing education and training are needed.
Recommendation D:
Ensure that copy and paste practices are regularly monitored, measured and assessed.
Health care provider organizations and vendors need to work together to create audit tools and policies to monitor the use of copy and paste by providers. By auditing use, they can help ensure the integrity of the clinical record, as well as the quality and safety of care. Auditing can also be used to gather information on what type of data are commonly copied and pasted to potentially create new solutions or tools.
The next time you decide to use any workarounds, consider their potential downstream effects and anticipate unanticipated consequences. If there is a need to copy and paste, make sure that the above recommendations are in place.
If you have further recommendations, please contact the Patient Safety Department for assistance. Happy charting!