Preventing Dictation Errors for Advanced Practice Clinicians - Activity ID 3280

Course Instructions

Thursday, September 15, 2022, 12:00 AM - Monday, September 15, 2025, 12:00 AM


AMA PRA Category 1 Credits™ (0.50 hours), Contact Hours (ANCC) (0.50 hours), Non-Physician Attendance (0.50 hours)

Emergency medicine providers are increasingly using voice recognition programs, such as Dragon Direct Voice Recognition Program, to document encounters. In reviewing closed malpractice claims, The Doctors Company identified dictation errors as a significant patient safety risk factor. The following case highlights the importance of timely recognition of dictation errors to ensure accuracy of the permanent electronic health record (EHR). This is particularly important when using a voice recognition program to document encounters in the busy emergency department. In this case, the voice recognition system was Dragon Direct Voice Recognition Program.  

Factors contributing to the emergency department dictation error highlighted in this case include:

• Lack of provider training
• Not following hospital policy and procedure
• Failure to read available medical records
• Failure to recognize and explore discrepancies
• Lack of clinical judgment in medication management 
• Failure to document informed consent 

Further, the clinical indication for a brain MRI order was never clarified by MRI staff, resulting in a missed study, which might have led to earlier diagnosis and treatment.

Learning Outcome Statement: Learners will demonstrate application of knowledge and skills related to preventing dictation errors by scoring 80% or higher on the post-test.   

To obtain credit and a certificate of completion, learners must score 80% or higher on a post-test and complete a program evaluation.

Learning Objectives apply to all professions.

1. Identify dictation errors involving clinical information impacts patient safety and determine how they may potentially cause malpractice claims.
2. Implement ways to improve accuracy of signed clinician notes in the ED when using voice recognition programs to generate medical records.
3. Propose curriculum for hospital policy education when voice recognition programs are used.
4. Summarize key communication factors in care transitions that can lead to transitions in care problems.
5. Educate colleagues about the Black Box warnings pertaining to abrupt cessation of Xarelto in patients with atrial fibrillation.

The Doctors Company is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. The Doctors Company designates this activity for a maximum of 0.5 nursing contact hours. Learners should claim only the credit commensurate with the extent of their participation in the activity.

The Doctors Company is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical educational activities for physicians. The Doctors Company designates this activity for a maximum of 0.5 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclaimer
The information and guidelines contained in this activity are generalized and may not apply to all practice situations. We recommend that legal advice be obtained from a qualified attorney for specific application to your practice. The information is intended for educational purposes and should be used as a reference guide only.

State Requirements for Continuing Education
Please see your state licensing organization for continuing education requirements for your profession and specialty.

Accessibility
The Doctors Company is committed to ensuring that its programs, services, goods, and facilities are accessible to individuals with disabilities as specified under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Amendments Act of 2008. If you have needs that require special accommodation, please contact the program coordinator or our CPE Coordinator.

Mitigation of Relevant Financial Relationships

No individual in a position to influence the content of this program has disclosed ineligible financial relationships with commercial interests.