Manglende dokumentasjon som viktig faktor for medhold hos Norsk Pasientskadeerstatning

Abstract

Studies from different countries implicate that inadequate documentation in patient journals result in patient injuries. The methods we use to register patient injuries in Norway today are not suitable for registering patient injuries when they are caused by inadequate documentation. This is a problem because we need knowledge to be able to work preventive with this problem. We wanted to see if the data collected by the Norwegian System of Patient Injury Compensation (NPE) could give us some more information about this topic. In addition to looking at the extent of inadequate documentation as an underlying cause for patient injuries in cases that was met with approval, we have looked at the distribution among different special fields, and on the consequences this led to for the patients involved. From our data we saw that patient injuries caused by inadequate documentation appears in the data from NPE. Over a four-year period 114 cases were given approval because of inadequate documentation. There were three special fields that occurred more often than others: Cosmetic- and plastic surgery, odontology and orthopedics. What outcome this had for the patients could vary from “cosmetic result not as expected” to death. Our conclusion is that analysis of NPE’s databases can be an important supply for identifying areas that should have more focus in the preventive work regarding patient injuries today. We have seen that poor documentation and communication is a factor that leads to patient injuries. These results can contribute to increased awareness of high quality documentation.