Friday, June 23, 2006

Medical Transcription Errors

Although this story about outsourced medical transcription errors in England has generated concern for the secretaries and outraged the administrative directors there, this problem has been in existence for years, regardless of whether records are transcribed locally or overseas. You see, there are good transcriptionists with lots of experience and a facile understanding of medical terminology, and there are illiterate neophytes who clearly flunked English and Grammar 101 in high school. Typically transciptions in hospitals are recorded to a central "pool" and retrieved by a well-meaning transcriptionist at a later time. The caliber of the transcriptionist is usually highly variable this way, since one hour they're dictating an orthopedic procedure and the next hour a cardiac procedure. And when they hit an ophthalmology or cardiac electrophysiology procedure, it's a whole new ball game again.

I am particularly fond of one well-meaning transcriptionist who changed the name for anatomic location of the conduction system of the heart in a woman (known as "Bundle of His") to the "Bundle of Her" (since she was a woman). Now it might have been cute at the time, but this was not a transcriptionist from overseas - this person came from our own back yard - and medicolegally this error could have had significant consequences regarding my intregrity and competence in the court of law.

So what have the Medial Error Police done to curb the cost of transcription for doctors? Simple. Make us type our procedures ourselves! Now in some ways, this might save time, since the errors I make are usually quickly corrected. But the new electronic medical records of today permit the use of "smart phrases" (also known as 'canned text') to speed typing of our reports. You can bet that this "cut and paste" technique in people who are in a hurry will also provide a slew of transcription problems since doctors don't always proof their canned text. Canned text with anatomic localization terms (like "left" or "right") buried within them, if not carefully scruitinized, could lead to later difficulties for all if the canned text word "left" was not changed to "right" in a patient with an actual right-sided knee replacement, for instance.

It would be interesting to know that other transcription errors have been discovered out there by my colleagues in the blog-o-sphere. It could make for some humorous and illustrative reading.

--Wes

1 comment:

Barry Watts said...

I don't know where to begin. As a *trained* medical transcriptionist, I come across such errors all the time, many by transcriptionists with much more experience than myself, but little knowledge of medical terminology, anatomy, etc. One of my favorites is "peroneal rash". Another is "mediastinotomy" when the doctor or radiologist is saying "median sternotomy" (or vice versa). There are so many such errors that I kept a list at one time, thinking a book on the subject would make for humorous reading and possibly even awaken the public to how little hospital administrators care about the accuracy of healthcare documentation. My computer crashed and I lost the list, but this is an issue all doctors and their patients should be concerned about.