News: Copy and paste issues affect patient safety

Since the advent of electronic medical record (EMR) systems, CDI professionals have known that physician copy and paste errors pose a threat to accurate documentation. Consequently, these errors can also negatively affect patient safety as well, according to a report from the National Institute of Standards and Technology (NIST).

Not only can the copy/pasted data inaccurately represent the patient’s condition and episode of care, but it can deprive future healthcare providers of valuable patient information. “Using outdated information, truncating information, or including a large amount of potentially extraneous information can all lead to safety issues,” Lorraine Possanza, patient safety, risk and quality program director at the ECRI Institute said in a release from the ECRI Institute regarding the study.

The ECRI release suggests four methods to prevent the copy/paste errors from happening:

1. Provide a way of making the copy/paste material easily identifiable in the EMR
2. Ensure that the provenance of copy/paste material is easily available
3. Ensure adequate staff training and education regarding copy/paste use
4. Monitor, measure, and assess the copy/paste practices regularly

While neither the official report, nor the release from ECRI mention the role of CDI, CDI professionals can certainly make a difference in the accuracy of the chart and ensure that the copy/pasted material is correct. The accuracy of the chart is a direct concern of a CDI professional; being aware of copy/paste issues will ensure that the documentation and patient safety remain paramount.