Learning objectives: Transcription errors in physician dictations may lead to establishment of an incorrect diagnosis which may be prevented by electronic documentation and further confirmation before making patients aware of serious medical problems.
Case information: A bilingual Hispanic female (Patient 1) established care with a new intern. At her second visit, a transcription error occurred with another patient’s (Patient 2) dictation from the same day being transcribed with Patient 1’s information on it and placed in Patient 1’s chart. Patient 2 was HIV positive. At follow-up, Patient 1 was thought to be managed by an outside HIV clinic per the last office note and a viral load and CD4 count were ordered but no medications refilled. Patient 1 was subsequently seen several times and confirmed to the physician that she followed at an outside HIV clinic. Cell counts and viral loads were consistent with treatment. Patient was seen after the clinic transitioned to electronic medical records (EMR) and agreed to referral to in-house HIV clinic. Subsequently, the patient called distraught, stating she did not have HIV.
Discussion: Several preventable errors occurred in assigning the HIV diagnosis. The transcription error in a patient unknown to the intern led to a lack of questioning the diagnosis. Normal labs reassured presumed compliance with HIV treatment. The outside HIV clinic typically did not communicate with PCPs, so nothing was felt to be amiss. Cultural and language issues contributed to the patient not correcting the physician. The EMR was pre-loaded with the incorrect diagnosis. Grave prescribing errors were avoided purely by luck. Physicians should cautiously give sensitive diagnoses and ensure confirmatory testing has been performed. When establishing a relationship with new patients, learners must meticulously review the chart and clarify inconsistencies.
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