Our recent article 'Thinking of using a scribe? What you need to know’ generated some keen interest from members. The article looked at the medico-legal issues doctors in Australia should consider before using a scribe and highlighted research on the use of onsite scribes conducted at Cabrini Health in Melbourne.
Lead researcher, Associate Professor Katie Walker, Director of Emergency Medicine Research at Cabrini Health and her co-authors provide an update on the latest results from their study published in the BMJ. A General Practitioner member also recounts his experience using a secretary and dictaphone while working as a Junior Resident Medical Officer.
We read your article on scribe medico-legal issues with interest. We would like to update your members on the most recent research published by our group. This is the first scribe patient safety data of its kind, published anywhere in the world.
The study, Impact of scribes on emergency medicine doctors’ productivity and patient throughput: multicentre randomised trial analysed emergency physician productivity, with and without scribes. A secondary outcome was a patient safety incident evaluation regarding scribes.
Scribes, scribe-trainers and physicians were encouraged and reminded repeatedly throughout the project to voluntarily report any patient safety events to the Emergency Medicine Events Register. The register is a cloud-based, privileged incident reporting system, available to Emergency Department patients, families and staff in Australia and New Zealand. The data custodian and major sponsor is the Australasian College for Emergency Medicine. Importantly, only incidents relating to scribes were available for analysis, there was no comparative analysis of the event frequency in the non-scribed shifts.
All reported scribe patient safety incidents were evaluated by two widely-published leaders and experts in emergency medicine patient safety: Dr Kim Hansen, Director of Emergency Medicine, St Andrew’s War Memorial Hospital, Brisbane and Dr Carmel Crock, Director of Emergency Medicine, the Royal Victorian Eye and Ear Hospital, Melbourne.
Overall, there were 5098 consultations where a scribe was allocated to an emergency physician or senior registrar. The study sites were Cabrini, Dandenong, Monash Children’s Hospital, Austin and Bendigo emergency departments (roughly equal exposure to scribes).
Sixteen patient safety events were reported. A detailed description of each incident can be found in table 5 of the open-access manuscript. The event rate was roughly 1:300 consultations. In all cases, the incident was identified and prevented (a near-miss). There were no major incidents identified during the study.
Patient safety events prevented
In 50% (8/16) of the reports, a scribe was enabled to be an intelligent observer within the team, noted an event about to happen and prevented the event (often not one of their own patients). We strongly advised providers working with scribes to allow the scribe to speak up if they noticed a potential incident.
- Scribes prevented an incorrect patient being taken to radiology.
- Scribes noticed visiting consultants reading and making decisions on incorrect patient ECGs and intervened.
- Scribes read paramedic handover sheets (printed some time after the physician had seen and managed the patient) and identified important information that was lost in verbal handovers (paramedic->nurse->doctor).
- Scribes ensured treatment areas were appropriately cleaned after occupation by patients with multi-resistant organism infections.
Patient safety events possibly contributed to by scribe presence
A recurring theme (7/16 incidents) involved a patient being incorrectly selected (by either the scribe or the physician) in the Electronic Medical Record (EMR) and having an investigation ordered.
In one case, a physician ordered a CT on the EMR whilst the wrong patient chart was opened. The scribe observed this and corrected the error.
Scribes are a potentially vulnerable, junior, health care worker, often undertaking their first healthcare role. They are at risk of occupational violence, psychological stress and infectious diseases, just like all other emergency workers and require more support than experienced workers.
A scribe did not realise they could leave a room when a patient became aggressive during a consultation.
IT systems may not be well integrated to support scribes and we suggest extensive testing prior to scribe program implementation. A scribe requires IT permission setting to use an EMR, but the functionality you request may not be the functionality you obtain.
For example, a scribe booked an outpatient follow-up appointment for a patient using their hospital EMR. It appeared to be accepted on-screen. The patient did not receive an appointment as the scribe had not been enabled to access appointments via EMR security settings.
Emergency Departments are noisy and scribes may not be able to hear everything discussed in the room. All patient encounter documentation undertaken by scribes must go through a process of careful review, then verification by the physician (and we suggest attestation as well). The physician must read, edit and sign-off the notes every time. We strongly suggest a process is established for this.
A scribe couldn’t hear the physician or patient correctly whilst a nebuliser was running. On leaving the room, the physician undertook documentation as the scribe captured little in-room information.
The scribe and physician may not always realise what the other is doing.
A scribe assigned their physician to a patient electronically. The physician did not realise this. The scribe did not prompt their physician. After a prolonged patient wait for the physician, the error was identified.
A scribe placed two patients’ home medication on a physician’s desk at once. The physician wrote up all medications in the first patient’s chart without checking the name on each medication box. The error was identified and corrected by the physician.
The patient safety incident review was a secondary outcome of the study rather than its primary focus. Voluntary reporting of incidents is only one method of identifying risk and incidents. True pictures of the impact of an intervention require multimodal evaluations. We also note there was no comparator group and hence the baseline incident rate (without scribes) is unknown.
This is the first scribe patient safety incident evaluation. Overall, the study demonstrated that scribes are likely to be safe but like any new intervention, providers and administrators need to be aware of their strengths and limitations.
Scribes should be enabled to speak up if they think they see something untoward happening. Systems and processes need to be established to routinely require checks of scribe work and there should be a focus on correct patient identification. Physicians and scribe-trainers should appreciate how little exposure the scribes have had to healthcare prior to this entry-level role.
The main outcomes of the study show there are tremendous community benefits to be derived from implementing scribe programs. Scribes allowed physicians to see more patients (16% more total patients, 25% more primary patients (excluding handovers and medical triage consultations). Patients spend 19 minutes less in emergency departments and the role is cost-effective.
We know from previous Australian work that we can train scribes in Australia. We also know that patients accept scribes and doctors want to work with scribes. This role will allow Emergency Department capacity building in a fiscally responsible way and we hope that hospitals will consider scribe program implementation in a fully informed way.
Associate Professor Katie Walker, Director of Emergency Medicine Research, Cabrini, VIC
Dr Melanie Stephenson, Australasian College of Emergency Medicine Research Trainee, Cabrini, VIC
Dr Kim Hansen, Director of Emergency Medicine, St Andrew’s War Memorial Hospital, QLD
Dr Carmel Crock, Royal Victorian Eye and Ear Hospital, VIC
Thank you for this article. We are all aware of the need for accurate and contemporaneous medical records. Pathology and radiology referrals containing quality clinical information greatly assist providers of these services. Good hand-over and referrals enhance our system. I note the concerns of the ‘anti-scribe’ group with interference in the thinking/contemplative phase of note keeping. Having a third person present does pose privacy concerns.
May I suggest another possibility which goes back to the 1980s. I had the pleasure of working as a sole Junior Resident Medical Officer at the old Peter MacCallum Cancer Clinic in Melbourne. It was a busy breast cancer unit with chemotherapy and radiotherapy services. The ward accommodated around 24 inpatients and there was a busy day procedure schedule as well as various ward rounds and outpatient services to attend. I was provided with a secretary and dictaphone. As I went about my business the relevant voice messages were recorded and the tape swapped out each hour or so with my secretary. She would present me the typed version for checking and signing usually within the next hour. I could also voice request her to do various clerical tasks such as make an appointment or track down pathology results etc. It was so liberating for a person with a writing style that exceeds the worst perceptions of our craft. There was far more time to engage with the patients and their journey. As all notes were typed, it was much easier to follow the clinical record. Referrals and requests were more complete. Discharge summaries were usually given to the patient as they left!
Having access to a secretary at such a junior stage provided insight into how valuable a good secretary could be and the relevant training. Rather than having a typing pool somewhere in the hospital, why not assign junior doctors their own personal secretary? It would be interesting to see the cost/benefit when all factors are considered.
Thank you for the article which reminded me of my most enjoyable term as a junior doctor.
General Practitioner, TAS