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Documentation Errors or Pizza? The lifecycle of a radiology reporting error

NEWS 10.11.2013

Ever think about the lifecycle of a documentation error?  At SpeechCheck, that’s pretty much all we think about.  Well, that and the clear superiority of Chicago-style pizza to any other carbohydrate-intensive food.  Did you know that enjoying a pizza is a three-stage process?  First you go to the restaurant, then you order the pizza, and finally you eat it. Outstanding!

Like the process of enjoying a pizza, radiology report errors have a three-stage lifecycle.  However, none of the three stages is enjoyable, and you don’t get that full, satisfied feeling at the end.  Here’s a brief description of each stage:

CREATION of the documentation error.  All reporting errors have the same underlying cause:  the radiologist failed to catch a mistake before signing a report.  Think about it:  Physicians rarely dictate something they don’t intend to say.  Instead, they dictate exactly what they mean, and are misunderstood by the speech recognition system or transcriptionist.  When they fail to correct a mistake and electronically sign the report, the error enters the patient’s record and stage one of the lifecycle is complete.

CATCHING of the documentation error.  The responsibility for catching the mistake usually falls to the referring physician.  This shouldn’t be his responsibility, but the reality is that this is the most common way for documentation mistakes to be found.  It’s embarrassing, and unprofessional.  And the process for notifying the radiologist of the error is far from standard.  The referring physician might call the Radiology Director, or the radiologist directly.  A fax with a snarky comment might be sent back to the Imaging Department.  Or maybe lower level staffers communicate back and forth about the mistake, which saves time for the physicians but delays the third stage of the lifecycle, which is …

CORRECTION of the documentation error.  The correction process always involves rereading the image and redocumenting the result.  This assumes, of course, that the original radiologist is available.  If he isn’t, another radiologist will need to be brought into the loop, in which case you end up with two results on the same case.  Hopefully the interpretations are similar!

Updating the documentation creates another set of issues.  The flawed report has already been signed, of course, and cannot be edited.  So a new report is created, or perhaps an addendum to the original report.  Now there’s another problem – which report is going to be seen first in the patient’s record?  How much manual work is required to point an EHR user to the proper result instead of the erroneous record?  The process for updating documentation varies by hospital, often involves multiple staff members, and is usually … cumbersome.

THE MORAL OF THE STORY.  When it comes to documentation mistakes, it pays to remember the old adage:  “There’s never time to do it right, but there’s always time to do it over.”  Quality improvement initiatives in radiology documentation result in fewer documents to correct.  And the fewer reports you have to fix, the more time and money you can apply to other, more enjoyable processes.  Like a Giordano’s deep dish pizza.

Posted by: Ken Schafer

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