A new study by patient-safety researchers published in the BMJ reports that medical errors are the third leading cause of death in the United States. While providers need to focus on ensuring patient safety while providing care, they should also ensure medical transcription outsourcing to the right company to avoid preventable documentation errors. The recent death of a patient due to a documentation error has put the spotlight on medical transcription service companies.
In May, the StarTribune reported that a Minnesota nursing home was facing flak for the second time in just over a month for neglect in the case of a patient who died after a medical transcription error.
A state Department of Health investigative report found that nurses at the facility had wrongly entered a physician’s order for blood-thinning medication on the wrong person’s medical record. The error went unnoticed by multiple nurses for nine days, resulting in the patient’s death caused by a stroke due to blood clots in the brain. The investigation revealed that the nurses lacked medication competencies. In another case, a patient in another Minnesota nursing home was mistakenly given a 10 times higher dose of morphine than prescribed — with fatal consequences.
How Nurses Can Avoid Documentation Errors
Such errors and many others can be avoided if nurses ensure strict adherence to the rules of medical charting and organizational policy and procedure (P&P). Recommended measures include:
- Recording all pertinent health or drug information
- Recording all nursing actions
- Recording that medications have been administered or discontinued
- Recording in the right patient’s medical record
- Recording drug reactions or changes in the patient’s condition
- Transcribing all orders and doing so accurately
- Ensuring legible and complete records
Medical Transcription Outsourcing – A Feasible Option for Good Documentation
A reliable medical transcription company can help physicians’ practices and hospitals maintain professional clinical documentation. Medical transcriptionists in established companies are knowledgeable about medications, new surgical instruments, and even new diseases. They are motivated, have excellent research skills, and constantly update themselves with new revisions. With good listening and typing skills, they can transcribe physician dictation quickly and correctly and provide feeds to electronic health records (EHRs). They can also comprehend different accents.
Every leading medical transcription service company has stringent quality control measures. After the reports are transcribed, they are formatted, scrutinized and edited for errors in translation, punctuation or grammar, and checked for consistency and possible medical errors. This strict QA process ensures 99 percent accuracy in the patient record and helps prevent serious errors. Other benefits of outsourcing medical transcription to the right company include customized TAT, affordable rates, HL7 integration and HIPAA compliance.