Dictation Errors in the Emergency Department (Claims Corner CME)

Description

Emergency medicine providers are increasingly using voice recognition programs, such as Dragon Direct Voice Recognition Program, to document encounters. In reviewing closed malpractice claims, The Doctors Company identified dictation errors as a significant patient safety risk factor. The following case highlights the importance of timely recognition of dictation errors to ensure accuracy of the permanent electronic health record (EHR). This is particularly important when using a voice recognition program to document encounters in the busy emergency department. In this case, the voice recognition system was Dragon Direct Voice
Recognition Program.

Factors contributing to the emergency department dictation error highlighted in this case include:
• Lack of provider training
• Not following hospital policy and procedure
• Failure to read available medical records
• Failure to recognize and explore discrepancies
• Lack of clinical judgment in medication management
• Failure to document informed consent
• Further, the clinical indication for a brain MRI order was never clarified by MRI staff, resulting in a missed study, which might have led to earlier diagnosis and treatment.

Objectives

After completing this activity, learners will be able to:

• Identify dictation errors involving clinical information impacts patient safety and determine how they may potentially cause malpractice claims.
• Implement ways to improve accuracy of signed physician notes in the ED when using voice recognition programs to generate medical records.
• Propose curriculum for hospital policy education when voice recognition programs are used.
• Summarize key communication factors in care transitions that can lead to transitions in care problems.
• Educate colleagues about the Black Box warnings pertaining to abrupt cessation of Xarelto in patients with atrial fibrillation.

Disclosure

No individual in a position to control or influence the content of this activity has reported relevant financial relationships with commercial interests. No commercial support was provided for this activity.

Disclaimer

The information and guidelines contained in this activity are generalized and may not apply to all practice situations. We recommend that legal advice be obtained from a qualified attorney for specific application to your practice. The information is intended for educational purposes and should be used as a reference guide only.

Course Developers

Robin Spinelli RN, MS, Patient Safety Analyst, The Doctors Company

Susan Shepard, MSN, MA, RN, CPHRM, Senior Director, Patient Safety and Risk Management Education, Department of Patient Safety and Risk Management, The Doctors Company

Johanna Lackner, MPH, MSW, Senior Director, Continuing Professional Development, Department of Patient Safety and Risk Management, The Doctors Company

Complies with State Requirements

Please SEE the Federation of State Medical Boards overview of Continuing Medical Education requirements by State. 

Technical Requirements

The activity is best experienced using the most current browser: Firefox, Chrome, Safari, or Microsoft Edge. Internet Explorer is not supported on this platform. All activities featuring audio must have a speaker. To view graphic images and references that appear in separate "pop-up" windows, JavaScript and session cookies must be enabled on your computer. Adobe Acrobat Reader may be required for certain activities.

Contact Us

If you have questions, contact educationsupport@thedoctors.com or call 800.421.2368.

Resource

Visit our Resource document for this program.