From 3M Health Information Systems
The Oops Factor: Not All Documentation Errors are Created Equal
When reviewing and evaluating healthcare documentation from a quality and integrity perspective, a QA reviewer is looking to capture and address any error, regardless of source and severity. However, some errors are more critical in nature because of their potential impact upon patient safety, care, or treatment. Other errors may have an impact upon documentation quality, but their presence does not change the meaning of a document or affect patient care. In this post I would like to discuss critical errors discovered through documentation QA, but stay tuned for future posts addressing noncritical errors and educational feedback opportunities.
According to the Healthcare Documentation Quality Assessment and Management Best Practices established by AHDI and AHIMA for use by the medical transcription industry in 2010, errors considered to be critical have the potential to affect patient safety, care, or treatment. In medical transcription situations, when a quality check on a document finds a critical error, the highest negative point value is applied against the transcriptionist’s quality score because of the seriousness of potential consequences that could occur, and the document will fail the quality review.
In 2014, AHDI and AHIMA collaborated again to look at QA processes from the perspective of clinician-created documentation, and the Clinician-Created Documentation: Reinstating Quality Assurance Programs to Safeguard Patients and Providers resource kit was released in July. When reviewing documentation created by clinicians, the goal is to find and address critical errors quickly so that they are not repeated or perpetuated. Although there is no scoring or point values in this type of QA, the list of critical errors defined in the new resource kit is consistent, yet more detailed, than the 2010 list.
The following categories describe the various types of critical errors and why QA review by a knowledgeable and experienced healthcare documentation specialist is so important.
Wrong medication/wrong dosage: Documenting the wrong medication and/or the incorrect dosage has huge potential to cause harm. For example, what may be incorrectly interpreted as “210 mg oxycodone,” should actually be, “two 10 mg oxycodone.” The most prominent example of a medication error in my memory is the story of Sharon Juno, a frail, chronically-ill patient who died after being administered 80 units of Levemir insulin instead of the proper dose of 8 units. A good summary of the Juno case and its implications is found here starting on page five.
Wrong lab value outside the normal range: Lab values are another common area for typos and incorrect interpretations, especially when they are dictated. For example, “Patient’s potassium was in the 6s,” could easily be misinterpreted as “Patient’s potassium was in the 60s.”
Wrong patient/wrong content (demographic errors): This category includes patient-encounter information that when incorrect could compromise patient safety such as a patient identification numbers, relevant dates, and author and/or authenticator identification. For example, if a report on 19-year-old John Smith indicates a history of prostate problems, you’ve probably got the wrong John Smith.
Unapproved abbreviations: The Joint Commission has an official “Do Not Use” list of abbreviations that should be avoided in documentation because they are commonly misinterpreted. For example, the abbreviation IU for International Unit should not be used because it is often mistaken for IV (intravenous) or the number ten, especially when handwritten.
Medical word misuse: An incorrect word can potentially lead to an inaccurate diagnosis, incorrect medical decision-making as well as inaccurate billing of the patient’s account. Examples of word misuse include mixing up hypotensive and hypertensive, regular and irregular, no for known, etc.
Incomplete or missing data: This category includes omissions that compromise clarity of the information (such as dictating numbers without units, terms, or decimal points). It also includes holes in the documentation that if not found in QA review would likely be discovered and addressed through queries by clinical documentation improvement, as in, “If it isn’t documented, it didn’t happen,” which can negatively affect coding, billing, and reimbursement.
Incorrect side/site: Which kidney should be removed? Which arm has the fracture? The documentation needs to state the side or site consistently. Other instances of this problem include exchanging a body location with one that sounds similar, such as “peroneal” for “perineal.”
Incorrect template/work type: This type of error happens most frequently in procedure reports when a procedure template is chosen incorrectly. For example, the laparoscopic hysterectomy template is selected when the patient had a vaginal hysterectomy, or a tonsillectomy template is selected when the adenoids were also removed.
Incorrect carbon copy distributions attributed to physician selection: This error category is intended to flag potential HIPAA risks due to improper disclosure of PHI to unassociated physicians and other unauthorized recipients.
Inconsistencies: This category addresses omitted or added words that change content and have the potential to compromise patient safety. For example, if the history of present illness indicates that the patient has weakness, but the musculokeletal section in the review of systems says that patient has normal strength, this calls the patient’s true status into question. Other inconsistencies may be introduced through misunderstanding of dictation by a speech recognition engine, as in “Left ureter stone causing hydronephrosis (swelling of the kidney),” incorrectly being translated as “Left ureter stone causing hydrocephalus (fluid on the brain).”
I encourage all healthcare organizations to implement a QA program for healthcare documentation that goes beyond clinical documentation improvement to find and address all critical errors that could harm patients and create risk for the organization. Healthcare documentation specialists who already serve as medical transcriptionists and speech recognition editors are great candidates for this new role in protecting documentation integrity, regardless of where it originates.
Jill Devrick, Product Solutions Advisor with 3M Health Information Systems, is Immediate Past President of the Association for Healthcare Documentation Integrity (AHDI).