Preventing Dictation Errors for Advanced Practice Clinicians
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.
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Description of the Professional Practice Gap (PPG)
In reviewing closed malpractice claims, The Doctors Company identified errors in dictation/documentation led to erroneous diagnoses and treatment. This course highlights the importance of recognizing and correcting dictation errors, clinical judgement and communication lapses as contributing factors associated with erroneous diagnosis. Communication, thinking processes, and education are highlighted in this case study.
Learners will demonstrate application of knowledge and skills related to preventing dictation errors by correctly answering the questions that follow the Case Study.
After completing this activity, learners will be able to:
- Identify dictation errors involving clinical information that 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.
Kimberly Hathaway, MSN, RN, CPHRM, CPHQ, Director Patient Safety Healthcare Quality & Risk Management, The Doctors Company
Johanna Lackner, MPH, MSW, Senior Director, Continuing Professional Development, Department of Patient Safety and Risk Management, The Doctors Company
Accreditation and Disclosure Statements
The Doctors Company is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Commission on Accreditation.
The Doctors Company designates this activity for a maximum of 0.5 nursing contact hour. Learners should claim only the credit commensurate with the extent of their participation in the activity.
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.
This program is being offered for informational and educational purposes only from a Patient Safety Risk Management perspective and does not constitute legal advice. Laws vary from state to state, actual clinical situations often involve subtle differences and nuances from program scenarios or recommendations, and the recommendations provided in this activity may not apply to all practice situations. In complex circumstances, which present significant potential for an adverse event or litigation, TDC and the faculty recommend you consult directly with your corporate or personal counsel for professional legal guidance.
Complies with State Requirements
Please SEE the Registered Nurse and Licensed Practical Nurse CE Requirements by State.
If you have questions, contact firstname.lastname@example.org or call 800.421.2368.
Visit our Resource document for this program.