Avoiding CPSEs - Laboratory Medication Vital Signs

CRITICAL PATIENT SAFETY
ERRORS
Importance of avoiding CPSEs
© 2002-2013 Nuance Communications, Inc. All rights reserved. Page 1

What is a critical error?
A critical error is an error that can affect the medical treatment
and/or confidentiality of a patient.
Here are a few questions you can ask yourself to evaluate whether
an error is critical?
– Does this error affect the treatment/diagnosis of a patient’s condition;
falsifying a lab value, negating a symptom (includes any part of
physical exam or review of systems), a history, or a diagnosis?
– Does this error affect patient safety?: An incorrect medication or

medication dosage listed within a document, incorrect or omitted
allergy information.
– Does this error put a patient’s confidentiality at risk?: Wrong name

on the report or a carbon copy sent to an incorrect provider
2 CONFIDENTIAL | © 2002-2012 Nuance Communications, Inc. All rights reserved. HEALTHCARE SOLUTIONS
Examples of Critical Errors
Dictated: The patient has no history of diabetes

Transcribed: The patient has a history of diabetes (history error)
Dictated: The patient is a 45-year-old patient

Transcribed: The patient is a 49-year-old patient (patient safety
error)
Dictated: HEART: Regular rate and rhythm

Transcribed: HEART: Irregular rate and rhythm (symptom error)
Dictated: Please send a copy to Dr. Davidson

Transcribed: Copy sent to Dr. David Smith (patient confidentiality
error/HIPAA)
Impact of CPSES
A well-publicized newsworthy example was in December 2012.
A Baldwin County jury in Alabama returned the largest civil wrongful

death verdict in the county’s history in the case of Sharon Juno. This
patient was administered a fatal dose of insulin as the result of a
transcription error in the patient’s medical record. This resulted in a $140
million medical malpractice judgment delivered against the hospital and
its outsourced transcription partner.
General guidelines
• Pay attention to the patient’s health story. The patient’s symptoms or previous
history will many times lead up to the numeric value such as an abnormally high lab
value or a low vital sign. Ask yourself if the value corresponds to the patient’s current
situation and/or diagnosis?
• Listen for the number of syllables dictated. You may be able to eliminate some choices
that way.
• Be aware of soundalike numbers such as 15 and 50.
• Don’t trust the text provided by speech engine. Always verify the text to what was
dictated. Your expertise is critical to ensuring the edited report is accurate and all
required edits are made. Missed edits can result in the speech engine not improving
the draft quality because the system is being trained that the missed edits are not
required.
• Consult normal ranges for laboratory tests and verify dosages for medications.
• It is always advisable to leave blank if MLS is unsure of the exact word or number.
Do not make unintelligent guesses. It’s not a science experiment. Someone’s life may
be on the line.
• Proofreading without headset to avoid nonsensical errors.

General guidelines
• Medication errors - We must always be sure to check the medication and its
treatment options for various diseases to avoid medication errors.
– Route of administration and dose interval must be listened twice like bid/tid
– Medication dosage errors – referring the correct dosage using drug reference.
• Numerical errors. Numbers can be a problem for transcriptionists. The “teen”

numbers can be confused with “ty” numbers, as in 13 / 30, 14 / 40, 15 / 50, 16 / 60, 17
/ 70, 18 / 80 and 19 / 90.
– Lab errors – Cross refer with normal lab values.
– Date errors – always check admit and discharge dates if any
– Vital signs error – abnormal vital signs must be checked with symptoms.
• Words that sound alike may include anything from brand and generic names for
medications, and like-sounding words, e.g. hypertension/hypotension,
apophysis/epiphysis, assess/access, etc.
– These errors can be avoided by careful listening and increasing or decreasing the dictation
speed.
– Cross-check if the author has dictated anywhere else in the report.
– Correlate with lab tests, for eg hyper/hypokalemia for potassium.
Laboratory Data – General Tips
• While transcribing values, always slow down the dictation.
• Leave a blank if you are unsure the very first time. Complete your file and
go back and listen to the values dictated.
• Do not trust the text provided by the speech engine.
• Use the laboratory data references to avoid errors.
• Always, always refer to the normal range for a lab test. Ask yourself,
“Does the value dictated fall within the normal range.”
• If you hear a number that is way outside the normal range, chances are
you are not hearing it right or the speaker is dictating it incorrectly. This
should prompt you to listen to the audio again, and if unsure leave a
blank.
• Soundalike numbers are very tricky, 16 versus 60. In such cases, you
MUST refer the normal range, and if still unsure, leave a blank.
Examples – Laboratory Values
Error Type FIESA Feedback Tip
ERROR CBC showed white See Normal Lab Values in

blood cells of 95.9 ENRICH. The normal range
for
white blood cells is:
WBC (male) 3.8 to 11.0
WBC (female) 3.8 to 11.0
Incorrect Values WBC (child) 5.0 to 10.0
(Lab/Vitals) CPSE
3.0 A value of 95.9 is so far outside
the normal range as to be
unbelievable.
CORRECTION CBC showed white This makes sense. It is within

blood cells of 5.9 the normal range for all
groups.
LABORATORY DATA:
ERROR WBC is 12, hemoglobin The hematocrit is usually
12, hematocrit 7 about 3 times higher than the
hemoglobin.
Incorrect Values
(Lab/Vitals) CPSE
3.0
LABORATORY DATA: See the Normal Lab Values in
CORRECTION WBC is 12, hemoglobin ENRICH. The normal range
12, hematocrit 37 for hematocrit is: hct (male) 39
to 54 hct (female) 34 to 47 hct
(child) 30 to 42
COMMENTS: A value of 7 is so far outside the normal range that it cannot be correct. A
value of 37 makes sense.
ERROR CRP 4.2 less than 5. A lab test will only have ONE value
assigned to it. The CRP (C-reactive
protein) value is 4.2. It does not make
sense for the dictator to make a
Incorrect comment like "less than 5" as the reader
Values can tell by looking at a value of 4.2 that it
(Lab/Vitals) is less than 5.
CPSE 3.0
CORRECTION CRP 4.2. ESR 5. Look at related tests. Go to

www.labtestsonline and look up CRP.
Related labs will be listed. "CRP may
sometimes be ordered along with an
Erythrocyte Sedimentation Rate (ESR),
another test that detects inflammation."
ERROR Refer Normal Lab Values. The normal

bilirubin 26. values for total bilirubin are: 0.2 to 1.4
mg/dL. A value of 26 is so far outside the
normal range, there is no way that can
Incorrect be correct.
Values
(Lab/Vitals)
CPSE 3.0
CORRECTION
bilirubin 0.6. A value of 0.6 makes sense as it is just
above the lower end of the normal
range.
BMP stands for "basic
RROR BMP is 86 metabolic profile." It is the
name of lab panel, and it has
many individual labs that fall
Incorrect Values under that panel. It will never
(Lab/Vitals) CPSE have a value/number
3.0 associated with it.
CORRECTION BNP is 86 BNP stands for "B-type

natriuretic peptide" and it is
one of the cardiac markers,
and it does have a specific
numeric value that is
measured.
BMP is a set of labs, cannot have one value, this is one way to find out BMP
COMMENTS: versus BNP
Vital Signs – General Tips
• Do the vital signs match the symptoms?

• Verify the dictated patient’s age with the date of birth in
the ADT feed/demographics
• Be careful with soundalike numbers. Refer to the normal

range
• Use Google to help you covert values (Celsius to

Fahrenheit, kilograms to pounds, etc.)
• Leave a blank if any value seems amiss.
Examples – Vital Signs
Always verify numbers. A weight
ERROR Weight today 7.8 kg, of 7.8 kg is equal to just over 17
pounds. Unless the patient is a
very young infant, this is not a
Incorrect valid weight.
Values .
(Lab/Vitals)
CPSE 3.0
A weight of 87.8 kg is equivalent
CORRECTION Weight is at 87.8 kg, to a bit over 193 pounds. This
makes sense for an adult patient.
Always correlate the dictated value with the rest of the dictation; in this case,
COMMENTS: looking up the age of the patient would have alerted you that this value is way
too abnormal.
Use Google to convert kilograms to pounds.
Today, his weight is This is not a valid weight. A weight
ERROR 3421 grams, down from is ONE number. A weight of 3421
birth weight of 35/55. grams is equal to 7.54 pounds.
Today’s weight of 3421 is "down
Incorrect from" some other number, and that
Values number MUST be higher than 3421
(Lab/Vitals) grams (greater than 7.54 pounds).
CPSE 3.0
Today, his weight is This makes sense. The baby

CORRECTION 3421 grams, down from weighed 3555 grams (or 7.84
birth weight of 3555. pounds) when it was born.
Visually proofreading your files would certainly draw your attention to such an
COMMENTS: error prompting you to either re-listen to it or make changes with the
formatting.

blood pressure 80/50 29.9 cm tall would make the
ERROR and 29.9 cm tall, patient just a tiny bit less than 1
foot tall.
Incorrect
Values
(Lab/Vitals)
CPSE 3.0 blood pressure 80/50 This makes sense. A patient who is
CORRECTION and 129.9 cm tall, 129.9 cm tall is 4 feet 2 inches tall
(patient is a child).
Visually proofread what you transcribe/edit to ensure it makes sense. In this

COMMENTS: case, converting centimeter to feet (in Google, type “cm to feet”) would have
certainly alerted you that the value transcribed/edited is way too abnormal.
Again referring the age of the patient would have also prompted you that the
value is abnormal.
ERROR heart rate of 1440 per A heart rate is the same thing as
minute, pulse. The normal range for an
adult is 60-100. A child's range is
Incorrect higher (70-120).
Values
(Lab/Vitals)
CPSE 3.0
CORRECTION heart rate of 140 per This makes sense.
minute,
Visually proofread what you transcribe/edit to ensure it makes sense. Refer to

COMMENTS: the normal range. In this case, a heart rate of 1440 means that the patient's
heart beats 1440 times in a minute or 24 times per second!
Her temperature is This value does not at all make sense. A
ERROR 9.6 temperature of 9.6 Fahrenheit would
only occur perhaps in the morgue. A
temperature of 9.6 Celsius is equivalent
Incorrect to 49.28 degrees Fahrenheit, again not
Values a viable body temperature.
(Lab/Vitals)
CPSE 3.0 Her temperature is This makes sense.
CORRECTION 98.6
Visually proofread what you transcribe/edit to ensure it makes sense. Always refer to
COMMENTS: the normal range.
Go to www.google.com and type "celsius to fahrenheit," and you can convert the
numeric value.
Medications and Dosages – General Tips
• Ask yourself what is the medication prescribed for? Does it match the treatment, medical history,
and/or symptoms? Look at clues within the report, such as diseases, symptoms being treated by the
medication.
• Always verify if a medication is brand name (capitalized) or generic.

• Use a reliable website to verify spelling, indication for use, and dosages.
• Be careful of soundalike medication names. Always verify dosages. Be careful of soundalike
dosages, such as 15 mg versus 50 mg.
• A tablet may be cut in half (scored tablets), so a half dose is also a possible prescribed amount.
• Is the patient allergic to the medication that was dictated? If so, flag the report.
• Numbers can often be confused in a drug dosage, especially the number 1 as it can be confused with
a lower case L.
• When a drug dosage and the amount of drug prescribed are in close proximity, it is acceptable but
not necessary to spell out numbers in drug dosages for clarity.
– Examples: After surgery, the patient was given Tylenol 650 mg one t.i.d. for pain. She was
given Glucotrol 5 mg two tablets p.o. q.a.m.
• The DO NOT USE abbreviation list states not to transcribe trailing zeros. This refers to only
medication-related doses. Do not use terminal zeros for doses expressed in whole numbers. 5 mg, not
5.0 mg
Examples – Medications and Dosages
The patient will Always verify abbreviations and slang
ERROR continue on Cipro terms. Go to www.medilexicon.com
and doxazosin in and type "doxy." The ONLY choice is
outpatient. "doxycycline," which is a broad-
spectrum antibiotic.
Incorrect
Medication
The patient will Note that Cipro is a quinolone, which
CPSE 3.0
CORRECTION continue on Cipro is a synthetic broad-spectrum
and doxycycline as antibiotic.
an outpatient.
MD dictated "doxy," which is a nickname for doxycycline, an antibiotic.

Doxazosin is Cardura, a blood pressure medication.
COMMENTS:
It makes sense to state that the patient will be taking a couple different
antibiotics. It does not make sense to combine an antibiotic (Cipro) and a blood
pressure medication (doxazosin).
The patient is to Always verify drug dosages,
ERROR take Levaquin 5 mg particularly for medications with
p.o. daily for another which you are not that familiar.
week.
Check www.pdr.net. Levaquin only
Incorrect comes in dosages of 250 mg, 500 mg,
Medication and 750 mg. A dose of 5 mg cannot
CPSE 3.0 possibly be correct.
The patient is to Note that Cipro is a quinolone, which

CORRECTION take Levaquin 500 is a synthetic broad-spectrum
mg p.o. daily for antibiotic.
another week.
Remember that a physician may specify how many tablets they would like the
patient to take, but they have zero control over what dosages are manufactured
COMMENTS: by the pharmaceutical company.
Remeron 1 p.o. q.i.d. The key here is "p.r.n. diarrhea."
ERROR p.r.n. diarrhea. Remeron is prescribed to treat
depression. While having diarrhea is
no fun, one does not require an
antidepressant to get through the
Incorrect ordeal.
Medication
CPSE 3.0
Lomotil 1 p.o. q.i.d. Lomotil makes sense since that drug
CORRECTION p.r.n. diarrhea. is an antidiarrheal.
Tip: Use your drug reference. If you do not have an updated drug book, then use
COMMENTS: a reputable online source. A very good one is www.pdr.net.
the patient's Lisinopril comes in dosages of 5 mg,
ERROR lisinopril was 10 mg, and 20 mg. A dose of 100 mg is
restarted at lower 5 times as high as the highest dosage
dose of 100 mg p.o. available, and that 100 mg dose is
daily. supposed to be LOWER than what the
Incorrect dose was previously.
Medication
CPSE 3.0
the patient's This makes sense. The patient is now
CORRECTION lisinopril was taking the lowest dose available of
restarted at lower lisinopril.
dose of 5 mg p.o.
daily.
Carrying out referencing would have alerted you on the dosages for the drug and
drawn your attention to this high dosage.
COMMENTS: Tip: Use your drug reference. If you do not have an updated drug book, then use
a reputable online source. A very good one is www.pdr.net.
1. Digoxin 1.25 mg Digoxin comes in the following
ERROR once daily. dosages: 62.5 mcg, 125 mcg, 187.5
mcg, and 250 mcg. If the dictator
gives the dose in milligrams, then use
Google to double check the conversion
Incorrect of micrograms to milligrams.
Medication
CPSE 3.0
1. Digoxin 0.25 mg A dose of 250 mcg converts to 0.25 mg.
CORRECTION once daily. There is no 1.25 mg dose available for
digoxin.
Tip: Use your drug reference. If you do not have an updated drug book, then use
a reputable online source. A very good one is www.pdr.net.
COMMENTS:
Collagenase sentinel This does not make sense.

ERROR apply topically daily.
Incorrect
Medication Collagenase Santyl Go to www.pdr.net and look up
CPSE 3.0 CORRECTION apply topically daily. "collagenase." There is only one result:
Collagenase Santyl.
Tip: Referencing this drug would have helped you avoid a CPSE.
COMMENTS:
ERROR 215 mg of Diamox Always research. Diamox is not

available in a 215 mg dose. It has one,
and only one, dose, which is 500 mg.
Incorrect
Medication
CPSE 3.0
CORRECTION 250 mg of Diamox The patient can use a pill cutter to cut
the tablet in half to arrive at a 250 mg
dose.
Tip: Referencing this drug would have helped you avoid a CPSE.
COMMENTS:
2. Tramadol. 3. Acetaminophen Any time you see a dose of

ERROR 37.5/325 two tabs q.6. #/# (with a virgule in
between), it always means
there are 2 drugs combined.
This list just states
Incorrect "tramadol," but there is no
Medication dose or any dosing
CPSE 3.0 instructions.
2. Tramadol/acetaminophen This makes sense;

CORRECTION 37.5/325 two tabs q.6. this is one medicine
(combination med)
The tramadol dose is 37.5
mg, and the acetaminophen
dose is 325 mg. The patient
is to take 2 tabs every 6
hours.
ERROR therefore, Kasten was not You know the drug sounds
brought to the bedside. like "kasten" or "kay-sten."
The report is about a
. patient who has cystic
Incorrect fibrosis.
Medication
CPSE 3.0
CORRECTION therefore, Cayston was not Go to www.empr.com and

brought to the bedside. type "cystic fibrosis."
Cayston is the 2nd hit.
Insomnia. Continue
ERROR with Zequel. You know what the drug sounds like
(zee quill.)
Incorrect
Medication
CPSE 3.0 Insomnia. Continue Go to www.pdr.net and type "zquil."
CORRECTION with ZzzQuil. You will be taken directly to ZzzQuil.
Alternatively, you could go to
www.empr.com and type “insomnia,”
and you will find ZzzQuil as one of the
results.
Remember patient
safety/patient care is our goal
and to achieve this, it is
important we avoid CPSEs by
using our critical thinking
skills.
© 2002-2013 Nuance Communications, Inc. All rights reserved. Page 30

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CRITICAL PATIENT SAFETY

© 2002-2013 Nuance Communications, Inc. All rights reserved. Page 1

– Does this error affect patient safety?: An incorrect medication or

– Does this error put a patient’s confidentiality at risk?: Wrong name

Dictated: The patient has no history of diabetes

Dictated: The patient is a 45-year-old patient

Dictated: HEART: Regular rate and rhythm

Dictated: Please send a copy to Dr. Davidson

A Baldwin County jury in Alabama returned the largest civil wrongful

• Be aware of soundalike numbers such as 15 and 50.

• Proofreading without headset to avoid nonsensical errors.

• Numerical errors. Numbers can be a problem for transcriptionists. The “teen”

• While transcribing values, always slow down the dictation.

• Do not trust the text provided by the speech engine.

• Use the laboratory data references to avoid errors.

Error Type FIESA Feedback Tip

ERROR CBC showed white See Normal Lab Values in

CORRECTION CBC showed white This makes sense. It is within

CORRECTION CRP 4.2. ESR 5. Look at related tests. Go to

ERROR Refer Normal Lab Values. The normal

CORRECTION BNP is 86 BNP stands for "B-type

• Do the vital signs match the symptoms?

• Be careful with soundalike numbers. Refer to the normal

• Use Google to help you covert values (Celsius to

• Leave a blank if any value seems amiss.

Use Google to convert kilograms to pounds.

Today, his weight is This makes sense. The baby

Error Type FIESA Feedback Tip

Visually proofread what you transcribe/edit to ensure it makes sense. In this

Visually proofread what you transcribe/edit to ensure it makes sense. Refer to

• Always verify if a medication is brand name (capitalized) or generic.

MD dictated "doxy," which is a nickname for doxycycline, an antibiotic.

The patient is to Note that Cipro is a quinolone, which

Error Type FIESA Feedback Tip

Collagenase sentinel This does not make sense.

Error Type FIESA Feedback Tip

ERROR 215 mg of Diamox Always research. Diamox is not

Error Type FIESA Feedback Tip

2. Tramadol. 3. Acetaminophen Any time you see a dose of

2. Tramadol/acetaminophen This makes sense;

CORRECTION therefore, Cayston was not Go to www.empr.com and

Error Type FIESA Feedback Tip

© 2002-2013 Nuance Communications, Inc. All rights reserved. Page 30

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