Do Written Disclosures of Serious Events Increase Risk of Malpractice Claims? One Health Care System's Experience

Disclosure of Adverse Events and Medical Errors: A Framework for Anesthesiologists

Ethical disclosure of adverse events (AE) presents opportunities and challenges for physicians and has unique ramifications for anesthesiologists. AE disclosure is supported by patients, regulatory organizations, and physicians. Disclosure is part of a physician's ethical duty toward patients, supports fully informed patient decision making, and is a critical component of root cause analysis. Barriers to AE disclosure include disruption of the doctor-patient relationship, fear of litigation, and inadequate training. Apology laws intended to support disclosure and mitigate concern for adverse legal consequences have not fulfilled that initial promise. Training and institutional communication programs support physicians in providing competent, ethical AE disclosure.

In their own words: Safety and quality perspectives from families of hospitalized children with medical complexity

BACKGROUND

Children with medical complexity (CMC) experience adverse events due to multiorgan impairment, frequent hospitalizations, subspecialty care, and dependence on multiple medications/equipment. Their families are well-versed in care and can help identify safety/quality gaps to inform improvements. Although previous studies have shown families identify important safety/quality gaps in hospitals, studies of inpatient safety/quality experience of CMC and their families are limited. To address this gap and identify otherwise unrecognized, family-prioritized areas for improving safety/quality of CMC, we conducted a secondary qualitative analysis of safety reporting surveys among families of CMC.

OBJECTIVE

Explore safety reports from families of hospitalized CMC to identify areas to improve safety/quality.

DESIGNS, SETTINGS AND PARTICIPANTS

We analyzed free-text responses from predischarge safety reporting surveys administered to families of CMC at a quaternary children's hospital from April 2018 to November 2020. Using a qualitative descriptive approach, we categorized responses into standard clinical categories. Three team members inductively generated an initial codebook to apply iteratively to responses. Reviewers coded responses collaboratively, resolved discrepancies through consensus, and generated themes.

MAIN OUTCOME AND MEASURES

Outcomes: family-reported areas of safety/quality improvement.

MEASURES

pre-discharge family surveys.

RESULTS

Two hundred and eight/two hundred and thirty-seven (88%) families completed surveys; 83 families offered 138 free-text safety responses about medications, feeds, cares, and other categories. Themes included unmet expectations of hospital care/environment, lack of consistency, provider-patient communication lapses, families' expertise about care, and the value of transparency.

CONCLUSION

To improve care of CMC and their families, hospitals can manage expectations about hospital limitations, improve consistency of care/communication, acknowledge family expertise, and recognize that family-observed quality concerns can have safety implications. Soliciting family input can help hospitals improve care in meaningful, otherwise unrecognized ways.

Risk Management-Obstetrics and Gynecology Perspective

The Obstetrics and Gynecology physician's likelihood to experience medical malpractice claims are higher than in other medical specialties. We will review the basic principles of health care risk management, the role of the risk manager, and the importance of health care risk management in risk mitigation for obstetrics and gynecology physicians. Attention is focused on medical record documentation, disclosure of adverse events, second victim programs, grievance management techniques, alternative dispute resolution concepts, regulatory inquiries including state licensure investigations, product failures, and electronic media strategies. Concluding, health care risk management may be used as a claim avoidance tool and provider protective vehicle for physicians.

Gender Bias in Risk Management Reports Involving Physicians in Training - A Retrospective Qualitative Study

OBJECTIVE

Gender bias, which contributes to burnout and attrition of female medical trainees, may manifest as disparate workplace evaluations. Here, we explore gender-based differences in perceived competence and professionalism as described in an institutional electronic risk management reporting system.

DESIGN

In this retrospective qualitative study, recurring themes were identified from anonymous entries reported to an electronic institutional risk management database from July 2014 to July 2015, and from July 2019 to July 2020 using inductive methods. This electronic system is often used by hospital staff to document complaints against physicians under the pretext of poor patient care, regardless of whether an adverse event occurred. Two individuals independently coded entries. Themes were determined from event indicator codes (EIC) using Delphi methodology and compared between gender and specialty using bivariate statistics.

SETTING

A multi-center integrated healthcare delivery system.

PARTICIPANTS

Risk management entries pertaining to physician trainees by hospital staff as written submissions to the institution's electronic risk management reporting system. Main outcomes included themes defined as: (1) lack of professionalism (i.e., delay in response, attitude, lack of communication), (2) perceived medical error, (3) breach of institutional protocol.

RESULTS

Of the 207 entries included for analysis, 52 entries identified men (25%) and 31 entries identified women (15%). The gender was not available in 124 entries and, therefore, categorized as ambiguous. The most common complaint about men involved a physician-related EIC (n = 12, 23%, EIC TX39) and the most common complaint about women involved a communication-related EIC (n = 7, 23%, EIC TX55). Eighty-eight (43%) entries involved medical trainees; 82 (40%) involved surgical trainees. Women were more often identified by their name only (n = 8, 26% vs. n = 3, 6%; p < 0.001). This finding was consistent in both medical (n = 0, 0% vs. n = 5, 31%; p < 0.001) and surgical (n = 2, 7% vs. n = 3, 25%; p = 0.006) specialties. In entries involving women, a lack of professionalism was most frequently cited (n = 29, 94%). Entries identifying medical errors more frequently involved men (n = 25, 48% vs. n = 7, 23%; p = 0.02).

CONCLUSIONS

Gender-based differences exist in how hospital staff interpret trainees' actions and attitudes. These differences have consequences for training paradigms, perceptions of clinical competence, physician burnout, and ultimately, patient outcomes.

Frequency and Nature of Communication and Handoff Failures in Medical Malpractice Claims

BACKGROUND

The Joint Commission has identified miscommunication as a leading cause of sentinel events, the most serious adverse events, but it is unclear what role miscommunications play in malpractice claims. We sought to determine the proportion of medical malpractice claims involving communication failure and describe their nature, including providers involved, locations, miscommunications types, costs, and the potential for handoff tools to avert risk and associated costs.

METHODS

We retrospectively reviewed a random sample of malpractice claims from 2001 to 2011, collected in CRICO Strategies' Comparative Benchmarking System, a national claims database. Two researchers reviewed cases to determine if a claim involved communication failure, its type, and potential preventability using a communication tool. Interrater reliability was assessed by dual review of 50 cases (81% agreement, κ = 0.62 for evidence of miscommunication). Claimant demographics, case characteristics, and financial data were analyzed.

RESULTS

Communication failures were identified in 49% of claims. Claims with communication failures were significantly less likely to be dropped, denied, or dismissed than claims without (54% versus 67%, P = 0.015). Fifty-three percent of claims with communication failures involved provider-patient miscommunication, and 47% involved provider-provider miscommunication. The information types most frequently miscommunicated were contingency plans, diagnosis, and illness severity. Forty percent of communication failures involved a failed handoff; the majority could potentially have been averted by using a handoff tool (77%). Mean total costs for cases involving communication failures were higher ($237,600 versus $154,100, P = 0.005).

CONCLUSIONS

Communication failures are a significant contributing cause of malpractice claims and impose a substantial financial burden on the healthcare system. Interventions to improve transmission of critical patient information have the potential to substantially reduce malpractice expenditures.

The Impacts of Disclosure and a Proactive Compensation Offer on Chinese Patients' Actions After Medical Errors

OBJECTIVES

This study aims to obtain evidence of the impacts of error disclosure and the impacts of a proactive compensation offer on Chinese patients' actions after medical errors.

METHODS

A total of 915 responses were collected from a questionnaire survey. Two fictitious cases (entailed moderate and severe harm) that involved error disclosure were described. One of 5 disclosure and compensation types was randomly provided to each participant. The 5 types were combinations of 3 disclosure types (no disclosure, partial disclosure, and full disclosure) and 2 proactive compensation offer categories (no offer and an offer), with the exception of no disclosure but a proactive compensation offer. The respondents were asked about their willingness to take actions if they were the affected patient.

RESULTS

The generalized ordinal logit regression model showed that error disclosure did not increase the likelihood of the patients taking action, such as changing physicians, complaining, or filing lawsuits. A proactive compensation offer decreased the patients' willingness to file lawsuits but had no significant influence on the other action choices. In addition, the patients' actions were affected by other factors, such as the severity of the error, age, sex, education level, being religious, prior error experience, and health insurance.

CONCLUSIONS

We suggest that "disclosure and compensation" programs are developed in China. To ensure their implementation, it is recommended that appropriate training is provided and that the disclosure culture in health care organizations is improved. Furthermore, laws or regulations are required that govern error disclosure and provide support for health care professionals and organizations.

How U.S. teams advanced communication and resolution program adoption at local, state and national levels

Widespread adoption of evidence-based new healthcare practice guidelines can take years to occur. Policy leaders frequently make decisions based on incomplete and often incorrect information. These policy decisions can result in wasteful healthcare spending and poor health outcomes. Proponents of a medicolegal policy, Communication-and-Resolution Program (CRP), were successful in their endeavor to get hospitals to implement CRP, state legislators to pass state laws to encourage CRP adoption by hospitals, and national medical societies to endorse CRP to their members. The purpose of this paper is to explain the methods used by nine teams in their efforts to accomplish these goals. We identify reasons for the successes, failures, and obstacles faced by the teams in their effort to advance CRP. Our hope is to educate groups on a potentially more expeditious method to advance evidence-based policy than other methods. We propose that advocates of an innovation determine the concerns and goals of all stakeholder groups impacted by the policy. The specific concerns of each group should be the focus of the message to that group. Teams should identify the opinion leaders of each stakeholder group who can champion the new policy to their peers. Teams can aid the opinion leaders in their communication efforts to their peer group. National groups should be organized to help teams in their endeavor to advance evidence-based policies.

Medical malpractice in spine surgery: a review

Medical malpractice is an important but often underappreciated topic within neurosurgery, particularly for surgeons in the early phases of practice. The practice of spinal neurosurgery involves substantial risk for litigation, as both the natural history of the conditions being treated and the operations being performed almost always carry the risk of permanent damage to the spinal cord or nerve roots, a cardiopulmonary event, death, or other dire outcomes. In this review, the authors discuss important topics related to medical malpractice in spine surgery, including tort reform, trends and frequency of litigation claims in spine surgery, wrong-level and wrong-site surgery, catastrophic outcomes including spinal cord injury and death, and ethical considerations.

Families as Partners in Hospital Error and Adverse Event Surveillance

Importance

Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection.

Objective

To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports.

Design, Setting, and Participants

We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient.

Main Outcomes and Measures

Error and AE rates.

Results

Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.

Conclusions and Relevance

Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.