I was reviewing a medical record today and came across a caveat I’ve seen before without paying a lot of attention.
Portions of this chart may have been created with Dragon voice recognition software. Occasional wrong-word or “sound-alike” substitutions may have occurred due to the inherent limitations of voice recognition software. Please read the chart carefully and recognize, using context, where these substitutions have occurred. The note may not reflect the data known because of improper importation.
Think about that: your medical record is filled with wrong words taken out of context because of errors in dictating software. It used to be, not long ago, that medical transcriptionists were paid to accurately type up a physician’s dictation that was then reviewed and signed off by the physician before it went into your chart. The original idea was pretty simple: your health care professionals – and consequently your mortality – depend upon the accuracy of the information in your chart.
But what if your chart was filled with a bunch of errors that looked and sounded right but were simply erroneous words and numbers spit out by mistake? And rather than reviewed for accuracy, the mistakes were just left in your chart with a caveat that reading the chart may yield gross misunderstandings even if read properly? And this is happening at the same time that students training for medical degrees are burning out at an “alarming rate”?
That is how things like this happen. Hospital Brain Surgery Performed On The Wrong Patient.
Like the Tampa cases where wrong limbs were removed from the right patient, corrections could include marking with patients brains and limbs not to be operated on with a giant ‘X’. Seriously though, at some point professionals need to come to terms with the idea of accountability. Humans make mistakes and we have a court system specifically designed to work out conflicts where the parties cannot agree upon a resolution themselves. Medical malpractice cases are complex, expensive and require large investments of time and money. For that reason, only the most serious of cases goes to trial. Please be careful when choosing your lawyer. Make sure they have experience litigating and trying medical malpractice cases.
