4 Ways We Make Misteaks
Nothing is more humiliating or human than the mistakes we make at work.
A few years ago, Spanish-speaking Pope Francis flubbed a vowel during a Vatican blessing, turning a common Italian word into something … well, pretty bad. Before shocked pilgrims could gasp, he corrected himself. A reporter later confronted him about his error, and Francis responded with “Pray for me. I make hundreds of mistakes a day.”
Nobody — not even the Pope — is perfect. We spend our days moving from error to error. We forget appointments, misdial phone numbers, send emails to the wrong person, miscode claims, roll past stop signs, and complain about a coworker before realizing nobody hung up the call. Imperfection is a problem we all face but don’t like to admit. It’s easier for us to blame something or somebody else for the error, rather than correct it.
In our field, we are quick to see other’s errors because we are trying to avoid mistakes. Professionals who are held to higher standards of accuracy feel the social license to point out mistakes made by others. It comforts us, and it helps us face our own frailties.
It may be personality, too. Research shows many types of introverts exhibit a strong preference for accuracy, especially in spelling and grammar. Subjects were asked to rate their impressions of email writers based on the authors’ mistakes in grammar and spelling. Introverts tended to be far more critical of the authors. Extraverts noted the mistakes but shied away from letting the errors mold their opinions of the authors. While nobody has done a wholesale personality preference study on medical coders, it’s safe to assume that a career of researching and assigning codes to medical services and supplies, especially at home, appeals to introverted personalities.
The mistakes we make often fall into four categories: skimming, looking but not seeing, multi-tasking, and over-confidence. They may overlap. Or they may reveal a systemic cause. The possibilities are as endless as the mistakes we make.
One way we make errors is by skimming. Major and minor gaffes result from our familiarity with something, too much to do, or fatigue. Pushed for time, we don’t read every word but instead skim over the content, reading what our brains expect to be in there.
This is a frequent problem in publishing. How often do you find typos on the Web, in your local newspaper, and other publications, like ours? As deadlines approach, editors read the same content for the third or fourth time and will not see a typo, or they’ll skim the content for any major goofs and miss the minor ones like “staff” for “staph.” Even though each Healthcare Business Monthly issue goes through multiple reviews by four editors, for example, familiarity and deadlines often derail a whole trainload of good intentions.
Skimming plagues coding, as well. For example, a prominent spinal surgery clinic noticed reimbursement dropped dramatically so the practice manager engaged an auditor. The problem, the auditor announced to a room of skeptical physicians surrounded by a phalanx of staff, was that the documentation didn’t match the codes assigned. The physicians erupted, and the auditor patiently continued.
It seemed that the coding staff, faced with an increasing quota of claims per day, were coding based on the diagnoses listed at the top of the operative reports and skimming the documentation. That seems safe, doesn’t it, since most of the claims were for injections and laminectomies?
Unfortunately, the surgeons had started cloning the same procedure description for the laminectomies into all the documentation, regardless of level, without mentioning it to anybody else. Payers were requesting documentation and, noting the inconsistency, rejected the claims. They then received the same documentation over and over again from harried staff. Accounts receivable piled up.
The root causes? Staff cut corners to keep up; and they were so familiar with the content, they skimmed the documentation. Both the surgeons and medical coding and billing staff were culpable, and it cost the clinic hundreds of thousands of dollars.
The cure? Read each word, read the document backward, or have someone unfamiliar with the content read it.
Looking but Not Seeing
We look but we don’t always see, even though it’s right in front of us. For example, when codes for drug-eluting stents were introduced, I wrote a whole book chapter about drug-eluding stents. After my editor, failing to hide her amusement, explained the error, I realized I’d created a whole new class of stents that flee, rather than introduce, medications to the artery.
I knew the difference, but I was exhibiting selective awareness. Some of the most injurious and irritating mistakes are because we don’t pay attention to something that wasn’t there. Here are some real examples:
- Does the patient have type I or type II diabetes?
- Is the physician talking about the ilium or the ileum?
- Was the child examined by a pediatrician or a pedophile?
- Where was the sinus the provider treated?
- Did I just code posterior spine surgery because I overlooked the unusual anterior approach?
There have been several experiments where subjects watched films with the expectation of a certain action and, because they were affixed on that action, they totally missed something else going on in the film. The most famous is an experiment with a group of college students passing a basketball. The test subjects were told to count the number of times one team got the ball. Unseen by nearly all the test subjects was a student dressed as a gorilla walking through the scrimmage.
It’s easy to miss the details. Complex information can include items that slip past as we’re distracted by a flood of facts. Badly constructed documentation can hide vital elements necessary to be accurate. (This is why journalists try to load the first paragraph of a story with the most important items.)
How to avoid this? I keep a growing list of terms I often confuse (like eluting and eluding) and consult it so often I recognize the words or terms that will trip me up. I also follow Atul Gawande’s advice in “The Checklist Manifesto,” and develop checklists for specific situations. What must be in the documentation to assure the provider did what they said they did? If you see a limited set of reports, build checklists, and make sure they include what must be included — or that you’ve seen what must be included.
Multi-tasking Equals Forgetting
The Buddha reportedly told his followers that “If you’re in the kitchen, cook,” meaning be fully present and avoid distractions when you do something. A good example of a distraction is addressing more than one claim at once or coding while checking in patients. Having multiple screens up on your computer, answering phones, talking to patients, and educating providers are common multi-tasking.
In Why We Make Mistakes, author Joseph Hallinan said, “Indeed the gains we think we make by multi-tasking are often illusory. That’s because the brain slows down when it has to juggle tasks.” He points to research showing that test subjects, faced with two identifying colored crosses and geometric shapes, took at least a second longer to respond when both were shown at the same time.
Switching from task to task creates other problems — one being that we forget what we’re doing or planned to do. Researchers found that when subjects were asked to resolve one problem and then, before completing the first, given a second problem, they forgot the first problem 40 percent of the time.
The most unnerving effect of multi-tasking is what is called unintentional blindness. This is especially evident when you do something while driving. For example, a driver deeply engrossed in a conference call may miss a Stop sign.
Fortunately, women appear less susceptible to the effects of multi-tasking. But if you’ve accidentally dressed your toddler son in his sister’s clothes while focusing on something else, you know that nobody is truly immune. Multi-tasking can be trouble.
A solution? Concentrate on the task at hand and complete it, and then move on to the next. If you have too many loose ends to tie, you’re apt to forget one, or several.
Lean in. You can do it. How hard can it be? For a lot of us, it can be impossible, but we don’t care. Over-confidence is one of the major causes of errors.
The same naive chutzpah that fuels “I’m first” dashes to the stage in a karaoke bar shows up all the time in our work. We often take on tasks for which we’re untrained or unprepared. Worse yet, if we are truly incompetent, we are often the last to realize how far afield we are. In their paper Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments, Justin Kruger and David Dunning explain: “The same incompetence that leads them to make wrong choices also deprives them of the savvy necessary to recognize incompetence, be it their own or anyone else’s.”
For example, the person who takes on the chargemaster without proper skills may be the last one to ask if they know how to do it or if they’re doing a poor job. The self-awareness of the truly competent is a telltale sign that the person doing the task is the right one for the job. Sadly about 25 percent of those in this situation never perceive their failure, Kruger and Dunning discovered.
How to boost confidence, without being too confident? Take advantage of training available through AAPC, your local chapter, and other sources. If you question your ability, you are on the right track.
Request evaluations. When we receive consistent, honest feedback, it helps us grasp our performance and our competency. It helps most of our colleagues, as well.
Errors Help Us Grow
The mistakes we make and observe are excellent teaching moments. They sneak up like those memories ready to embarrass us late at night.
Our education, interests, emotions, and prejudices prompt us to define our realities. We are slaves to the limits of our experience and perceptions. Arthur Schopenhauer wrote in Studies in Pessimism, “Every man takes the limits of his own field of vision for the limits of the world.” But that world keeps changing. Coding and billing, grammar and writing styles continue to evolve.
That means we see a lot of mistakes, real and perceived. It’s irritating, but it also presents the opportunity to walk in the person who errs’ shoes. Why was the mistake made? Were they busy? Rushed? Unknowingly incompetent? And then ask this: Does this mistake affect me personally? If not, letting it go may be the best way to fix it.
Why We Make Mistakes; Joseph T Hallinan. Broadway Books, 2010
The Invisible Gorilla; Christopher Chabris and Daniel Simons, Harmony, 2009
Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments; Justin Kruger and David Dunning. Journal of Personality and Social Psychology (pages 1121-1134, Vol. 77, No. 6, 1999).
If You’re House is Still Available, Send Me an Email: Personality Influences Reactions to Written Errors in Email Messages; Julie E. Boland, Robin Queen. PLOS One: https://journals.plos.org/plosone/
Studies in Pessimism; Arthur Schopenhauer, Cosimo Classics, 2010
The Checklist Manifesto; Atul Gawande, Picador, 2009