Each day it seems as if we’re once again alerted to medical record errors incidents. Reports showed in 2014 that preventable medical errors are the 3rd largest killer in the U.S. At 400,000 deaths each year, it’s definitely not something to ignore. These errors, as The Journal of Patient Safety explains, are Preventable Adverse Events (PAEs).
PAEs vary based on their category:
• Errors of omission
• Errors of commission
• Errors of context
• Errors of communication
• Diagnostic errors
In 2015, the National Academies of Sciences, Engineering, and Medicine issued an Institute of Medicine report. It detailed how diagnostic errors, the greatest offender of medical errors, are preventable. Moreover, that “the issue requires urgent change.” To counteract this, the NASEM suggests 8 aids for healthcare diagnosis challenges.
A way to address the situation is by “developing and deploying approaches to identify and learn from errors to reduce near misses in clinics.” Some think the EHR is culpable for the errors. The Atlantic published an article by Dr. R. Gunderman stating that “A recent study at Johns Hopkins University showed that hospital interns spend only 12% of the time interacting with patients.
They spent 40% of the time interacting with hospital information systems. The real-life patient is getting covered up by gigabytes of data. The article revealed that Dr. Gunderman admitted a new patient whose intern reported the status was “post-BKA (below-knee amputation).” When asked about the patient, an exam found that the patient’s extremities were actually intact!
It just so happened that a speech recognition (SR) system had produced the patient’s chart. It changed the record to BKA rather than DKA (diabetic ketoacidosis) — four hospital admissions prior!
This happened because the “modern technology” of SR has inherent flaws. It can’t replace human eyes. The account from NASEM says nothing about SR mistakes. Speech recognition isn’t anything new. Starting in the 50s, it’s been in the mainstream use since the 90s with the arrival of Dragon Dictate.
Medical Transcriptionists are a great way to solve the problem of error prevention and capture. Recent errors in medical records are something transcriptionists would catch. Take a patient with simple hypothyroidism for instance. The patient got misdiagnosed with a code for “Congenital Hypothyroidism with Diffuse Goiter.” He noted the error after reviewing his electronic brief post-visit.
Using transcriptionists, they can question the error of diagnosis at the point of care while it’s becoming a permanent part of the patient’s electronic report. Errors in healthcare are preventable with good electronic health record stewardship. Having an experienced human set of eyes is essential to preventing critical errors.