Dictation Errors in the Emergency Department (Claims Corner CME)
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
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.
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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.
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.
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.
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
Continuing Education Credit
The Doctors Company is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical educational activities for physicians.
The Doctors Company designates this activity for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Complies with State Requirements
Please SEE the Federation of State Medical Boards overview of Continuing Medical Education requirements by State.
If you have questions, contact firstname.lastname@example.org or call 800.421.2368.
Visit our Resource document for this program.