Will Jurors Believe it Was Really Just a Typo?
Will Jurors Believe it Was Really Just a Typo?
Careless errors carry legal risks
The final statement,"Doctor X is leaving with the patient," dictated by Corey M. Slovis, MD, professor and chairman of the Department of Emergency Medicine at Vanderbilt University Medical Center in Nashville, was regarding a critically ill patient who was being accompanied by the hospital's chief of trauma to the operating room. This was later incorrectly transcribed as "Doctor X is sleeping with the patient."
"The lesson is that one needs to be very vigilant when signing your name to any document," says Slovis. "Unfortunately, when one has seen 20 patients on a shift, it is easy to speed read."
If the word "not" is omitted, it will appear a patient had a positive finding, as with "chest pain not associated with exertion" becoming "chest pain associated with exertion." "This is an issue I've seen more than once," says Slovis. "A simple miss like that can allow plaintiff's attorneys to get very interested."
To avoid this, he advises carefully reviewing all dictated records to be sure these say what you intended.
In one case reviewed by Jonathan D. Lawrence, MD, JD, FACEP, an ED physician at St. Mary Medical Center in Long Beach, CA, and assistant professor of medicine at Harbor/University of California Los Angeles Medical Center, a typist left out the word "no," and the inaccurate statement "there were signs of infection" made itself into the patient's chart.
"Unless you are willing to spend a little bit of time proofreading the dictation, these errors can come back and bite you," he says. One potential pitfall is that some dictation systems use default macros such as "ENT exam, normal" to speed up the transcription process.
"That's all well and good if you performed the exam," says Lawrence. "The problem comes if you are using the macros to save time and you didn't actually do what is in the default examination, and a question arises as to whether you actually performed a particular exam."
If jurors have emotionally identified with the plaintiff, adds Slovis, they'll tend to disbelieve an EP who claims to have done something in error. "When the chart does not make sense, physicians run the risk of being seen as either indecisive or disorganized," he says. "It allows the plaintiff's attorney to allege many negative things that are then difficult to disprove."
Clarity is Best Defense
Slovis says that when an error is either perceived or occurs, the EP's best defense is to convey his or her assessment and why the EP is doing or not doing therapies or referrals. "The clearer we are in our history, physical, and assessments, the less likely we are to either be sued, pressured into settling, or losing in front of a jury," says Slovis.
While new generations of voice recognition software are making this charting method more accurate, says Slovis, "like all dictation methods, proofreading is required so that embarrassing errors don't get readily dictated."
Voice recognition offers all of the advantages of the dictated record, notes Lawrence, but carries an increased risk of transcription error. "To the extent that you don't proofread it or have the ability to edit what comes out, it could be problematic," he says.
The final statement,"Doctor X is leaving with the patient," dictated by Corey M. Slovis, MD, professor and chairman of the Department of Emergency Medicine at Vanderbilt University Medical Center in Nashville, was regarding a critically ill patient who was being accompanied by the hospital's chief of trauma to the operating room. This was later incorrectly transcribed as "Doctor X is sleeping with the patient."Subscribe Now for Access
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