Medication documentation error is one critical and significant cause of morbidity and mortality among patients. Recently, I handled a situation of a rejected claim following an error in the documentation of the patient medication and diagnosis. The patient’s record states that he was administered with a blindtumomab infusion. The infusion is a total contrast as the database actual medication was blood infusion. Checking into the system, I also realized that this atrocity is habitual as it has occurred to six times within the facility. Medication documentation error is thus a matter that needs to be taken with utmost seriousness considering that it bears huge financial constraints, affects the quality of care, and breaches legal issues that may expose the affected facility to the state of mistrust and eventually poor performance.
Financial Consequences
There are financial implications for medication documentation errors. Firstly, the facility can issue the treatment of a different infection which is costly. When a wrong infection is wrongly entered into the documentation records, the ripple effect is that a cheaper one replaces the right infection. This implies that the billing on a high-cost medication will be low. Therefore, the facility will lose finances and might possibly end up bankrupt. On the flipside, a cheap medication can be wrongly replaced in the records with an expensive one. A patient will thus be required to pay heavily over the same procedure. For example, the patient in the case was to be billed an additional $6,900 US Dollars. This could trigger the filing of a lawsuit from the patients’ family on the facility. The hospital might find itself dealing with an expensive lawsuit due to negligence and oversight.
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Consequently, clients will lose trust in the facility. Per se, retaining and recruiting of new customers will prove to be a daunting task for the facility. In addition, dealing with such errors will be time-consuming, alongside with investigation, litigation, and settlement. It will cost the management time and additional money to devise policies and revise rules that govern the same since such errors are impactful on the lives of the people and the hospital’s reputation.
Quality of Care
Berwick et al. (2018) define the quality of care as the extent to which medical services that patients and other individuals receive is improving the desired health outcomes. It is within the core of the facility that patients receive the best healthcare services. Therefore, the services are important and should meet the customer’s satisfaction while attaining the legal standards stipulated by the authorities. The presence of data entry errors within a health system thus goes contrary to such desires and expectations.
Legal Issues
The following are legal issues that relate to the data entry errors committed;
Risk For Medication Malpractices Claims
Despite the use Electronic Health Record (EHR) for keeping medical records, the physicians concerned with introduction and implementation of the system are at the verge of bearing the consequences arising from malpractices. During the transition from a new healthcare system, there is a high possibility of increasing the claims of medical malpractices (Erbay & Esatoglu, 2018). Such cases might attract lawsuits, whereby EHR supports the process following the availability of data and documentation that serves as a proof for the malpractice claim.
Likelihood of medical errors.
Despite putting more trust on the EHR to minimize medication errors, such systems are normally, prone to small mistakes that cause medical errors, and possibly, documentation errors. Overreliance on the system can lead to a trail of errors that may go unnoticed. Therefore, such errors will be hard to correct upon identification. A good example is the recurrence of a documentation error discussed seven times within the facility without being pointed out.
National Drug Code Application
National Drugs Code is a segment number that defines the code function of each drug (Kearsley, Lew, & Nardinelli, 2018). The first segment is called the labeler. It gives details of the manufacturer, packager, and distributor of a specific drug. The second segment is referred to as the product. The segment is a combination of three numbers that define the strength of a given drug and its corresponding dosage. The last segment, called the package code, identifies sizes and packages of drugs. Sometimes, the code can bear 11-digits, which is used for billing.
Steps to Report a Fraud
HIM needs to understand the specifications of the fraud that has been committed or is about to be committed. Data fraud, in this case, implies the misrepresentation of a client.
HIM needs to document the fraud. This should be put in writing. The step involves identifying those who have participated in the fraud. The HIM also has to collect as much information as possible relating to the fraud and transactions, if any that have been made.
HIM needs to protect themselves by taking actions if they are ever given out important details about patients that might have been used to commit the fraud.
Report the fraud to the hospital management for relevant actions to be taken.
Pharmacy Revenue Cycle Internal Audit
Conducting a pharmacy revenue cycle audit is important. The audit is done considering the multi-disciplinary duties of a health facility that starts from providers, coding, billing, and financial aspects. As such, the pharmacy department is faced by a number of challenges in documentation and tracking unused medicine. It is necessary that any unused drug is returned to the pharmacy and credited to the account of the patient provided that the charges were generated on the preliminary delivery. The systems and processes of drug distribution require periodic review to minimize stockpiling unused drugs and circumvention of the supply controls. The pharmacy needs a reconciliation of administered drugs to the billed ones. Consequently, this implies that when an audit is done, errors, like the one in this scenario, are identified since there will be a mismatch between the paid medications and the one administered.
Considerations in Conducting Pharmacy Revenue Cycle Internal Audit
The audit should point out opportunities that will facilitate improving revenues and minimizing the potential of billing errors. Correcting billing errors increases the integrity and trust of patients towards the facility. Intrinsically, patients will pay for drugs consumed, thereby boosting satisfaction, and confidence. Putting all the recommendations into consideration will bring about harmony between the patients and the health facility.
It is imperative to note that conducting the internal audit should also determine if a review on a sample of medication is evident to be backed up by a medical order and evaluating whether the orders comply with the guidelines. This will ensure that the correct medication is received and goes in compliance with the National Drug Codes. Additionally, drug codes ensure that the right drugs are supplied to hospitals.
The audit also considers reviewing the override report concerning the systems of distribution of drugs in order to evaluate if departments or consumers are circumventing controls. Besides, it evaluates if the hospital management is conducting an active, informed and timely review of the overrides. Conclusively, the audit confirms any discrepancies identified during the review and ensures that they are officially documented and investigated. Therefore, the audit acts as an arbitrator between the patients affected and the health facility in question.
References
Berwick, D. M., Kelley, E., Kruk, M. E., Nishtar, S., & Pate, M. A. (2018). Three global health-
care quality reports in 2018. The Lancet , 392 (10143), 194-195.
Erbay, E., & Esatoğlu, A. E. (2018). Content analysis of newspaper coverage of medical
malpractice. Health Sciences Research in the Globalizing World , 956.
Kearsley, A., Lew, N., & Nardinelli, C. (2018). A retrospective and commentary on FDA’s bar
code rule. Journal of Benefit-Cost Analysis , 1-23.
