Monday, September 24, 2007

Acceptable Margins of Error

It started off as one of those days.

  • Media reports indicated that another round of patients had had breasts and limbs removed from the wrong side of their bodies. In one or two cases, Board-certified neurosurgeons (who certainly should have known better), even operated on the wrong side of the patient’s brain!

  • While transcribing a Mohs surgical procedure, I listened to a resident insist that “the wound margins were debeveled and wildly undermined.”

  • Upon checking my e-mail, I read a message from a Pakistani firm which stated “We are looking for some good frenchized partner for transcription business. Keeping in view the extra ordinary cheeper skilled labour in our country, you can reduce your direct costs by a great deal..... Do u have any such policy?”

  • And, while walking down the aisle at Walgreens, I looked up and noticed signage pointing to products that could help shoppers suffering from “Dental Incontinence.”

The folly of what is allowed to pass for acceptable -- in both the medical field and the world around us -- is truly mind boggling. While offshore transcription firms eager to develop “frenchized” relationships are quick to boast of 98.5% accuracy, suppose we look at the other percentage points -- the number of errors that don’t make it into their marketing pitches.

Even if we go with an accuracy rate of 99.9%, do you have any idea what that means? According to popular statistics, it means that:

  • 12 babies will be given to the wrong parents every day

  • 107 incorrect medical procedures will be performed in one day.

  • 268,500 defective tires will be shipped in one year.

  • 291 pacemaker operations will be performed incorrectly in one year.

  • 20,000 incorrect drug prescriptions will be written in one year.

  • The Internal Revenue Service will lose 2,000,000 documents in one year.

As technology has allowed the medical transcription industry to process more data and transmit more documents, the demand for speedier delivery has caused statisticians and risk managers to make allowances for certain margins of error. No one likes to admit that these errors exist, but they do. Despite the best intentions (flagging of blanks, sending notes to doctors, demanding that physicians proofread their reports), many such errors end up in a patient’s medical record because they were not caught and corrected.

Several months ago I received an unnerving e-mail which demands to be shared. A medical transcriptionist wrote:

“The hospital I work at has been using a vendor who sends our stuff to India for almost a year now. My hope is that somebody with some power might hear about this and make it stop. Their quality is horrendous, and the really sad part is that the reputation of our department has probably been ruined since our dictators don't know one set of initials at the bottom of a report from another set in order to distinguish our own transcriptionists from the vendor’s. The following are a couple of gems we received back to revise the other day. Unfortunately, since we contract out approximately 50% of our volume we do not have the staff to proof and fix the reports they send back to us before they go to the doctors for signature. They're funny when you read them, but at the same time they're not when you consider they're part of a patient's medical record.”

  • “The patient's past medical history was well documented on her chest.” (should have been chart)

  • “Hearing was intact to lightening rod.” (should have been light finger rub)

  • “The patient should avoid his heart throb.” (should have been hot tub)

  • “The patient twisted his right ankle on returning from Iran.” (should have been a run)

  • "One patient's name was Overmeyer and they referred to the patient throughout the report as Ms. Overachiever.

“There are also so many more situations where the errors aren't so blatant. Unless you know the patient's history, you wouldn't know that the information is the opposite of what the report says. Or just inaccurate. JCAHO is at our facility this week. I wonder what their position would be on this subject. I'm sure the subject won't be brought up!”

As we hurtle toward the electronic medical record, it is much more likely that similar mistakes will continue to metastasize throughout a patient’s record until -- based on what a physician reads in previous reports in the patient’s chart -- it seems perfectly logical for surgeons to chop off the left instead of the right arm! So here’s the question for all the HIM directors and risk managers who claim to be concerned about the quality of patient care. How high must the body count rise before someone applies some brakes to the system? What will it take to stop the insanity? I mean, it’s not like we haven’t had plenty of warnings.

In 1968, Stanley Kubrick’s epic film 2001: A Space Odyssey gave audiences the first glimpse of what might happen when computers malfunction. Three decades later, Apple invoked memories of that famous command --Open the pod door, Hal” -- to launch its wonderfully satirical Y2K ad campaign.

In 1970, when Stephen Sondheim’s ground-breaking musical Company premiered on Broadway, the frenzied crush of life in a modern metropolis was captured in the following lyrics:

"Another hundred people
Just got off of the train
And came up through the ground
While another hundred people
Just got off of the bus
And are looking around
At another hundred people
Who got off of the plane
And are looking at us
Who got off of the train
And the plane and the bus
Maybe yesterday.”

While Sondheim’s Company focused its attention on a group of self-centered New Yorkers, Godfrey Reggio’s Koyaanisqatsi (1982) gave viewers an apocalyptic vision of what happens when urban life and technology collide with the environment. The film’s title was taken from a Hopi Indian word meaning “life out of balance.”

It’s interesting to note that, as part of its effort to select films which are culturally, historically and aesthetically significant, the Library of Congress added Koyaanisqatsi to the National Film Registry on December 27, 2000. In a bizarre twist of fate, a mere 51 days later the USS Greeneville sank the Japanese fishing boat Ehime Maru in an unfortunate collision which led to the Bush administration’s first foreign relations crisis. Writing to the editor of, retired USNR Captain John DeShazo -- an instructor of seamanship and navigation at the United States Naval Academy in the late '70s and early'80s -- asserted that:

“The USNA recruits technocrats to be midshipmen, people fascinated by electromechanical gadgets. They place more faith in electronic sensors than their own eyes. Without an appreciation for the power of human senses, no one learns to focus the attention on the environment in which a seaman's vessel actually exists...... Seamanship is not given a high priority in the U.S. Navy. I have personally observed this failing many times. On dark nights while conducting offshore sail training operations, I used to turn off all the electronics and require midshipmen to steer using the wind on their faces, the stars and the sea. They nearly always resented this exercise. They would say it was useless and saw no purpose in being deprived of modern electronic devices. They rarely understood their instructor's intentions of honing their ability to focus on details and concentrate on learning to understand the real life existence of their vessel in its environment. Modern American naval officers perceive themselves in the abstract, as if they were controlling their ships over the Internet.”

Like those patients who received surgery on the wrong side of their bodies, the incident involving the USS Greenville is a classic example of what happens when people

  • Become too dependent on technology.

  • Reward mediocrity instead of accuracy.

  • Develop a false sense of security because they have been deluded by so-called “acceptable margins of error.”

Is it any wonder that a proverb currently floating around the Internet suggests “Give a man a fish and he will eat for a day --teach a man how to fish and he will be killed by an American nuclear submarine.”

One of the most important lessons taught to medical transcriptionists is not to guess at dictation which is unintelligible -- and not to substitute medications that they think might be okay -- because one small error could cost a patient his or her life. It doesn’t matter whether you are a medical transcriptionist, a service owner, a transcription supervisor, a medical records director, a risk manager, a nurse or a physician. When the chips are down and you have to look at yourself in the mirror, what are you going to say is an acceptable margin of error in your documentation of patient care?

You’ll want to give that question serious thought. Why? Because the next time you get admitted to a hospital, there’s absolutely no guarantee that you won’t fall into an “acceptable margin of error” yourself.

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