Raposo Vera Lúcia
Faculty of Law, Macao University, Macao, China ; Faculty of Law, Coimbra University, Coimbra, Portugal.
GMS Health Technol Assess. 2015 Dec 10;11:Doc02. doi: 10.3205/hta000123. eCollection 2015.
The electronic health record represents a major change in healthcare delivery, either for health professionals and health institutions, either for patients. In this essay we will mainly focus on its consequences regarding patient safety and medical liability. In this particular domain the electronic health record has dual effects: on one side prevents medical errors and, in this sense, promotes patient safety and protects the doctor from lawsuits; but, on the other side, when not used properly, it may also generate other kind of errors, potentially threatening patient safety and, therefore, increasing the risk of juridical liability for the physician. This paper intends to underline the main human errors, technologic mistakes and medical faults that may occur while using the electronic health record and the ways to overcome them, also explaining how the electronic health record may be used in court during a judicial proceeding.
电子健康记录对医疗服务的提供而言,无论是对医疗专业人员和医疗机构,还是对患者,都代表着一项重大变革。在本文中,我们将主要关注其对患者安全和医疗责任的影响。在这个特定领域,电子健康记录具有双重作用:一方面可预防医疗差错,从这个意义上说,能促进患者安全并保护医生免受诉讼;但另一方面,如果使用不当,它也可能产生其他类型的差错,潜在地威胁患者安全,从而增加医生承担法律责任的风险。本文旨在强调在使用电子健康记录时可能出现的主要人为失误、技术错误和医疗过失以及克服这些问题的方法,同时还将解释在司法程序中电子健康记录如何在法庭上被使用。