There’s No Such Thing As Minor Errors In Medical Records

When it comes to the medical profession, errors can have massive consequences. A report from Johns Hopkins University School of Medicine shows how dire these errors can be, stating that medical errors are the third leading cause of death in the U.S. These errors, typically related to the action or inaction a doctor takes, all have obvious consequences, but medical errors can hurt patients in more subtle ways, specifically when it comes to documentation and medical records. A study from the Pennsylvania Patient Safety Authority found that patient safety errors are all too common with electronic health record use. The study found that errors occurred during every step of the medication cycle, including 38.1 percent during prescribing, 27.6 percent during transcribing, 8.8 percent at dispensing, and 32.2 during administration.

Record keeping is essential to the medical profession. The accuracy of this information is vital as even minor errors can have major consequences. Medical documentation is crucial at every stage of the care process, from facilitating billing and patient care, to serving as evidence to help doctors avoid lawsuits. Over the last decade, a major push has been made to digitize health information and make it more widely accessible.

As a medical transcription company, we deal in record keeping and medical data management daily, and found a recent article from Abby Norman, a science writer based in New England, very pertinent for helping to avoid errors in health records. Her interest in the accuracy of medical records began while working as a medical records clerk, which gave her an “incredible amount of insight into the inner workings of America’s healthcare system.” Her insights are important lessons for all of us working with sensitive and vital medical documentation and records.

1. Risks Of Automated Dictation

As a company engaged in medical transcription services, Ms. Norman reinforced our position of ensuring that ONLY trained medical transcriptionists, and not automated systems, handle transcribing dictations from doctors and medical professionals. Automation in the medical transcription industry gave her pause for concern. She views voice recognition software as an imperfect practice that “often requires additional double-checking by a real human.” Her feelings are based on the fact that minor errors, like a misspelling, can have consequences for malpractice suits, it can mislead a future provider, cause billing errors, or even confuse or mislead the patient when they review their records. She says that the more that humans are removed from the oversight process, the more often errors found their way into records “long enough to conceivably do some damage.”  

2. Risks of Doctor Error

Long shifts are a reality of being a doctor. At the end of a long day, mistakes can find their way into a dictation, Ms. Norman found. She remembers a time when a doctor dictated audio said that they operated on the patient’s left leg, only to later say it was the right. An automated system would only transcribe the correct word, it would not question or flag what was said the way a human proofreader would. One of the benefits of a medical transcriptionist is that they would usually catch this type of error, notify the medical records office, and the information could be verified.

It is essential that health care systems and providers ensure that the possibility of errors is minimized. When we review the Pennsylvania Patient Safety Authority study, we see that 27.6% of errors were due to transcription. That is unacceptable. At 2Ascribe, we strive for 100% accuracy. We help reduce medical transcription errors by:

  1. We ensure that our transcriptionists keep word lists for drug names (generic and Trade Names), specialty related vocabulary, and tests.
  2. We create Style Guides for clients with their specific feedback, including particular phrases a physician may dictate, drugs that they regularly prescribe and vocabulary particular to their specialty or location (for example, saying “Sick Kids” to indicate The Hospital for Sick Children (HSC) in Toronto).
  3. We track all feedback by client, transcriptionist, and editor. We note what kinds of errors are happening on the Style Guide, how often they happen and by whom.
  4. We assign clients to a particular pool of transcriptionists and a specific editor (or editors) who have good knowledge in the specialty being transcribed.
  5. Add another level of editing if necessary, especially for poor quality dictations.

2Ascribe Inc. is a medical transcription services agency located in Toronto, Ontario Canada, providing medical transcription services to physicians, clinics and other healthcare providers across Canada. Our medical transcriptionists take pride in the quality of your transcribed documents. WEBscribe is our client interface portal for document management. 2Ascribe continues to implement and develop technology to assist and improve the transcription process for physicians and other healthcare providers, and recently introduced AUTOfax. AUTOfax works within WEBscribe to automatically send faxes to referring physicians when a document is signed off by the healthcare professional. As a service to our clients and the healthcare industry, 2Ascribe offers articles of interest to physicians and other healthcare professionals, medical transcriptionists and office staff, as well as of general interest. Additional articles may be found at http://www.2ascribe.com.

This entry was posted on in Dictation Tips.

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