In many assisted reproduction clinics, it is taken for granted that safety depends on the IT system.
If there is an EMR (Electronic Medical Record), there is traceability, and if there is traceability, there is safety.
But reality is a bit more uncomfortable.
Most incidents do not occur because the system fails, but because small daily shortcuts become normalized and, when added together, end up compromising traceability.
These are some of the most common ones.
1. Shared users: when the system does not adapt to real use
This is probably the biggest traceability gap that exists… and also one of the most widely accepted.
It usually starts the same way: there is urgency, there is a lot of work, there is clinical pressure. The system does not quite fit the real pace of the team, and a practical solution is sought.
One single user for several people. At that moment, nothing seems to happen because the work gets done and the day goes on.
The problem comes later, when an action needs to be reviewed, a doubt arises, or someone asks what exactly happened.
When several professionals use the same user:
- It is not known who actually performed each action.
- Actions are no longer linked to specific individuals.
- The system stops being an “objective source of truth”.
At that point, the system can no longer respond:
- It does not know who did what.
- It does not distinguish decisions.
- It does not separate responsibilities.
An EMR does not record “actions”; it records people performing actions.
If there are no individual users, there is no real traceability. There is trust.
And trust is not a safety system and does not protect patients.
2. Validating in the system something that has already been done “outside”
This is another classic, and it often happens for the same reasons: pressure, high workload, shift changes.
The action is carried out first and then “entered” into the system.
The problem appears when this practice stops being occasional and becomes a habitual way of working.
Then:
- The EMR stops being the central point of the process.
- The logical sequence of events is broken.
- There is increasing dependence on memory.
- Temporal traceability is lost.
- The system has less capacity to detect inconsistencies.
That is why modern EMRs try to:
- Minimize manual writing.
- Facilitate immediate data capture.
- Reduce the distance between what happens and what is recorded.
When the EMR is used as a historical record instead of as a guide to the process, it stops protecting.
3. Correcting data without leaving a clear trace
In the day-to-day work of a clinic, correcting data is inevitable. Typographical errors, adjustments, clarifications… are part of real work.
The problem is not correcting. The problem appears when, upon correcting, the history disappears.
When the EMR allows critical information to be modified without making it clear that a change has occurred and without preserving the original context.
In those cases, the system shows an apparently clean process, but it has lost part of its history.
Traceability does not consist only of seeing the final correct data, but of being able to understand what happened during the process:
- What was recorded first.
- What was changed afterwards.
- Who did it and at what moment.
When changes are not clearly identified:
- Context is lost.
- Subsequent analysis becomes more difficult.
- And traceability is weakened, even if the system “works”.
4. When traceability depends on doing everything right
Most of these problems do not occur due to malpractice. They arise from day-to-day reality.
- From systems that allow it and processes that do not prevent it.
- From assuming that no one will share users.
- From taking for granted that no one will register late or correct without context.
But clinics do not operate under ideal conditions. They operate with people, pressure, and volume.
And when safety depends on everyone always doing the right thing, without real support from the system, traceability becomes fragile.
That is why traceability is not just a functionality of the EMR. It is the result of:
- Individual users.
- Well-designed workflows.
- Protected critical points.
- And systems that do not depend on memory or good faith.
Conclusion
Patient safety is not lost when someone makes a mistake.
It is lost when the system cannot say who did what, when, and why.
And very often, it starts with something as seemingly harmless as sharing a user.
