Download QA Categories - Association for Healthcare Documentation Integrity

Clinician-Created Documentation
Reinstating Quality Assurance Programs to
Safeguard Patients and Providers
QA Categories and Examples
These are examples and a starting point for QA staff. Facilities should customize this list to their specific
needs.
Critical Errors are likely to increase risk of patient
harm if left uncorrected.
It is recommended to correct all critical errors
immediately upon discovery and to provide
feedback and further training to prevent
repetition.
Wrong medication/wrong dosage
Examples: 15/50; mg/mcg; sound-alike drugs
(such as sildenafil, vardenafil and tadalafil)
Wrong lab value outside the normal range
Example: 15/50, 18/80
Wrong patient/wrong content (demographic
errors)
Examples: patient name/gender/age/race
discrepancies in report
Joint Commission—Unapproved abbreviations
Examples: cc - mL; U - unit; IU - international
units; SC or SQ - subcutaneous; R or Rt - right; L or
Lt - left; AS, AD, AU - left, right or both ears; OS,
OD, OU - left, right or both eyes; MS, MSO4,
MgSO4 - morphine sulfate or magnesium sulfate;
QD or QOD - daily or every other day; trailing zero
or lack of leading zero
Medical word misuse
Examples: hypo/hyper; negative/positive;
regular/irregular; no/known
Incomplete or missing data
Examples: Neurologic: 2+; Extremities show 2 to 3
over 4; X-ray shows pathologic fracture, no acute…
Incorrect side/site
Examples: Right/left; humerus/femur;
peroneal/perineal
Incorrect template/work type
Noncritical Errors are unlikely to increase risk of
patient harm but may adversely affect
documentation integrity.
It is recommended to correct noncritical errors
when possible and to provide feedback and
further training to prevent repetition.
Misspelled medications
Examples: Indur for Imdur, sildnafil for sildenafil
Wrong lab value typo (within same intended
diagnostic range)
Example: 73/74
Misspelling/Transposition of names
Mixing up the patient’s first and last name, i.e.
patient’s name is Barry James but the provider
enters “I’m seeing Mr. Barry today…”
Barry/Berry, Allen/Alan, etc.
Hospital—Unapproved abbreviations
Examples: MA4Es - moving all 4 extremities; ADAT
- Advance diet as tolerated; PPX - prophylaxis;
Dispo - Disposition; SAR - subacute rehab
Wrong word form/spelling/typos
Examples: obstructing/obstructive; feel/fill/fell;
staff/staph; retension/retention; lumbar/lumber
Failure to edit
Examples: speech recognition output, dictation
quality issues, nonsense sentences
Administrative templates
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Critical Errors are likely to increase risk of patient
harm if left uncorrected.
It is recommended to correct all critical errors
immediately upon discovery and to provide
feedback and further training to prevent
repetition.
Examples: vaginal vs. laparoscopic hysterectomy;
tonsillectomy vs. adenotonsillectomy; H&P vs.
Discharge Summary
Incorrect carbon copy distributions attributed to
physician selection
Example: Incorrect physician added to cc list by
the originator
Inconsistencies
Examples: HPI: Patient has weakness
Musculoskeletal: Normal Strength
Noncritical Errors are unlikely to increase risk of
patient harm but may adversely affect
documentation integrity.
It is recommended to correct noncritical errors
when possible and to provide feedback and
further training to prevent repetition.
Examples: Using incorrect patient
education/learning barriers template
Incorrect cc distributions attributed to
registration error
Example: Incorrect family or referring provider
entered at registration
Error examples
Medication formulation, dosage, administration: The nature of medication mechanism means that any
medication error is a critical error.
 Sound-alike drug names such as those found on the ISMP’s list of confused drug names
 Incorrect dosages, such as twice daily and 3 times daily, every day and every other day
 Incorrect route of administration, such as oral, rectal, IM, IV, subcutaneous, intrathecal
 Sound-alike numbers, such as 15 and 50, 7 and 11, or 50 and 60
 Missed decimal points, such as 1.0 and 10
 Missed digits, such as 80 and 180
 Incorrect units, such as mg and mcg, mL and nL
Laboratory values: Lab values may be critical if reported so inaccurately as to change the immediate
course of treatment, thus exposing the patient to likely risk, or noncritical if inaccurate but not changing
the immediate course of treatment, and thus less likely to expose the patient to risk.
 A white blood count of 60,000 documented in error as 16,000 would likely change the
immediate course of treatment and would be considered critical.
 A blood sugar of 130 documented in error as 140 would be less likely to change the immediate
course of treatment and might then be considered noncritical.
Patient identifiers and demographics: An incorrectly identified patient, a note placed on the wrong
patient’s chart, or an error in the patient’s age, race, or sex would all be critical errors as they are likely
to affect how the patient receives care, and thus are likely to cause patient harm.
Misuse of abbreviations: Use of abbreviations from the Joint Commission’s Official “Do Not Use” list
constitutes a critical error, as the Joint Commission has identified these abbreviations as particularly
Copyright © 2014, by the Association for Healthcare Documentation Integrity. All rights reserved.
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dangerous. In addition, many institutions maintain their own lists of unapproved abbreviations. It is
recommended that use of abbreviations from institutional lists be considered critical depending on the
anticipated patient safety risk level.
Word misuse: Critical errors of word misuse usually include misuse of a medical word or term and
change the meaning of the documentation such that patient harm is likely to result. Some examples of
critical word errors are:
 hypotensive for hypertensive
 regular for irregular
 no for known
 omission of a negative such as “no” or “not” or “non”
 abduct for adduct
 aversion for eversion
Some word errors may cause confusion but are not anticipated to put patients at risk of harm. Examples
of these are:
 obstructing for obstructive
 retention for retension
 misspelling of location names
 confusing common homonym English word pairs such as corral and chorale
Side and site errors: Critical errors of anatomy are likely to cause errors in procedures. Examples are:
 left and right
 anterior and posterior
 humerus and femur
 ilium and ileum
 cervical, thoracic, and sacral vertebra misidentification
 recto- and retroIncomplete or missing data: Incomplete phrases are likely to cause patient harm and thus are critical
errors. Additionally, some missing data have more indirect impact on patient care as reimbursements
are reduced and future patient care threatened. Examples are:
 Radiographic report states A/P and lateral views but does not identify location imaged
 Vital signs dictated as numerals only, without identifying related terms such as blood pressure,
temperature, pulse, etc.
 Numeric data dictated unclearly, e.g., “one two” instead of “one point two”
 “pneumonia” rather than “community-acquired pneumonia” [affects quality scores and
reimbursements]
Incorrect template use: Documenting using templates saves a great deal of time for busy providers, yet
presents new risks for selection of wrong templates or report types. Examples are:
 Vaginal hysterectomy template used for laparoscopic hysterectomy
 Tonsillectomy template used for tonsilloadenectomy procedure
 History and Physical report created instead of a Discharge Summary
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Protected health information errors: Errors of documentation that lead to PHI being released
inappropriately are critical because a) they place patients at immediate risk and b) they expose the
institution to legal and financial risk. Examples of critical breaches in documentation are:
 A provider adds a copy of a report to be sent to Jane Smith, MD, instead of Jane O. Smith, DO,
the patient’s primary care provider.
 Registration enters Jane Smith, MD, as the patient’s primary care provider instead of Jane O.
Smith, DO, and Jane Smith, MD, gets copies of all of the patient’s notes.
 Patient requests that no information on her chemical dependency treatment be shared with her
primary care provider, and all her CD notes are sequestered; however, after she is seen in the
ER, her ER visit note mentions the patient’s CD treatment in passing, and this note goes to her
primary care provider.
Failure to edit: Use of front-end and back-end speech recognition tools adds efficiency to
documentation, but it still requires editing to produce good documentation. Neglecting to remove
extraneous recognized text may be a critical, major, or minor error depending on what was not
removed.
 Critical: A provider using front-end speech recognition is interrupted by a colleague. The speech
recognition engine transcribes this conversation about another patient into the document. The
provider does not delete this extraneous text.
 Noncritical: A beeping monitor in the background of the dictation is inserted into the text as
“food food food food.” This nonsense text is not removed.
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