Medical reporting errors can have fatal consequences.
Last year, an Alabama woman with diabetes died after a transcription error resulted in administration of too much insulin.
Sharron Juno’s death, and the resulting $140-million verdict, are an extreme example of the risks associated with medical reporting errors, but any error in a medical report can put your patients and your organization at risk. In the best case scenario, you catch the error but still expend valuable time and resources making corrections.
One Fatal Error
Any time that a physician dictates and a transcriptionist transfers that information to a digital file, there’s a risk of error. In many cases, that risk is aggravated as institutions attempt to limit the high cost of medical transcription. That’s exactly what happened at the Alabama hospital.
Unknown to the physicians creating dictations, the hospital was outsourcing its medical transcription to a company that was shipping its work to an international shell corporation that in turn outsourced to transcriptionists in India—all in an effort to save 2 cents per line on the cost of medical transcription.
Sharron Juno’s death was caused by a transcription and the failure of her hospital to properly review their reports. Her Discharge Summary ordered 80 units of insulin. Her physician’s original dictation called for only 8.
Preventing Medical Report Errors
Many medical facilities are alleviating the costs—and mitigating the risks—of transcription by switching their medical record management to a synoptic reporting system. Such systems allow clinicians to enter data directly, and eliminate the need for costly transcription that opens the door to errors. If your institution is still reliant on transcription, understanding and protecting against the most common sources of mistakes will help to minimize transcription errors.
Why Transcription Errors Occur
There are many possible sources of transcription error, but some of the most common include:
- Poor sound quality, which makes it difficult for the transcriptionist to understand the clinician’s dictation;
- The non-standard format of many dictated reports, which may result in unclear statements or missing information;
- Transcriptionists who are not familiar with medical terminology;
- Sound-alike words that may confused transcriptionists with limited knowledge of the field;
- Inadequate (or no) proofreading of transcribed reports.
Avoiding Medical Transcription Errors
While no system is foolproof, the following measures will help keep your medical record management procedures error free and increase the likelihood that any errors introduced are discovered and corrected.
- Use equipment that will provide the best sound quality and ensure that it is well maintained;
- Encourage clinicians to follow a template or checklist when dictating, to ensure that all necessary information is included and make it easier for transcriptionists to follow;
- Use transcriptionists who are well trained and who are familiar with the terminology used;
- Make sure that your transcription service employs proofreaders and takes measures to correct errors before medical reports are returned to you;
- If you’re outsourcing, ask questions: make sure that you have up-to-date information about the training and language skills of the transcriptionists and proofreaders handling your work.
Medical record management can be as important to the successful treatment of patients as the quality of your clinicians and the equipment in your facility. Without accurate information, your clinical team can’t provide the best possible care. Whether you choose to upgrade to a synoptic reporting system that eliminates transcription errors entirely or to implement safeguards to improve the quality of your current medical reporting system, make sure that you’ve taken every feasible step to minimize errors.
Photo credit: ILO