Relationship between tort claims and patient incident reports in the Veterans Health Administration

Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers

BACKGROUND

Mandatory and voluntary reporting of adverse events is common in health care organizations but a more accurate understanding of the extent of patient injury may be obtained if additional sources are used. Patients in Sweden may file a claim for economic compensation from the national insurance system if they believe they have sustained an injury. The extent and pattern of reporting of serious adverse events in a mandatory national reporting system was compared with the reporting of adverse events on the basis of patient claims.

METHODS

Regional sentinel event reports were compared with malpractice claims data between 1996 and 2003. A sample consisting of 113 patients with deaths or serious injuries was selected from the malpractice claims data source. The medical records of these patients were reviewed by three chief medical officers.

RESULTS

Of the deaths or injuries associated with the 113 patients-25 deaths, 37 with more than 30% disability, and 51 with 16/o-30% disability-23 (20%) had been reported by chief medical officers to the National Board of Health and Welfare as sentinel events. Most adverse events were found in orthopedic surgery, and orthopedic injuries had more serious consequences. None of the patient injuries caused by infections were reported as sentinel events. Individual errors were more frequent in cases reported as sentinel events.

CONCLUSIONS

Adverse events causing severe harm are underreported to a great extent in Sweden despite the existence of a mandatory reporting system; physicians often consider them to be complications. Health care organizations should consider using a portfolio of tools-including incident reporting, medical record review, and analysis of patient claims-to gain a comprehensive picture of adverse events.

Can patient injury claims be utilised as a quality indicator?

OBJECTIVES

To examine the association between patient injury claims and well-known quality indicators and to assess whether claims can be utilised in performance measurement.

METHODS

Data were derived from administrative registers and comprised hip and knee replacement patients (n=34181) in Finland from 1998 to 2003. Hospital-level correlations were calculated between claims and quality indicators (5-year revision rate, 1-year deep infection rate, and 14-day readmission rate), while logistic regression analysis was used to analyze patient-level data for an association between claims and quality indicators.

RESULTS

Correlations between claims and revisions as well as claims and infections were statistically significant, with correlation coefficients ranging from 0.21 to 0.62. In the regression analysis, both the revision and the infection indicator had a positive and statistically significant association with filing a claim (OR 1.002; 95% CI 1.001-1.003 and 1.001; 1.00005-1.001, respectively) and obtaining compensation (1.003; 1.001-1.005 and 1.001; 1.0003-1.002, respectively).

CONCLUSIONS

A claims indicator has the potential to be applied as a quality indicator. It should be complemented, however, with other indicators or actions to improve its acceptability by health professionals and to mitigate its possible undesirable effects.

Incident reporting practices in the preanalytical phase: Low reported frequencies in the primary health care setting

OBJECTIVE

Incident reporting is commonly used to improve patient safety. The preanalytical phase of laboratory testing contains several manual error-prone tasks where mistakes can affect patient outcomes. However, the practical use of incident reports in this area has not been previously investigated in the primary health care setting, where the majority of the patients come in contact with health care.

MATERIAL AND METHODS

All staff responsible for venous blood sampling in 70 primary health care centres and in two hospital clinical laboratories (317 respondents, response rate 94%) completed a questionnaire.

RESULTS

Of the primary health care staff, 69% reported that they had never filed an incident report regarding venous blood sampling. Barriers for not filing incident reports often/always included lack of time (44%) and a complicated reporting procedure (27%). A higher proportion of staff with re-education (43%) had filed at least one incident report as compared to those without re-education (20%, p < 0.001). No differences in incident reporting practices were found between primary health care and hospital clinical laboratory staff.

CONCLUSIONS

The investigated incident reporting system is likely to underreport incidents in the preanalytical phase. Therefore, the ability to discover preventable system vulnerabilities needs refinement.

SHARED maternity care: enhancing clinical communication in a private maternity hospital setting

Midwives and visiting medical officers have a unique relationship within private hospital maternity settings. The effective exchange of accurate information between them is a fundamental element of patient safety and is vital to the success of the clinical handover process. The SHARED (situation, history, assessment, risk, expectation, documentation) project developed, implemented and evaluated a framework and support tools for improving clinical handover in two private maternity hospitals. The project included a pre- and post-study design using clinician surveys, chart audits, patient satisfaction surveys and a review of clinical incident data. A standardised approach to handover, using the SHARED framework with a standardised minimum dataset, improves the accuracy and appropriateness of information.

Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients

BACKGROUND

There is growing interest in the use of interactive telephone technology to support chronic disease management. We used the implementation of an automated telephone self-management support program for diabetes patients as an opportunity to monitor patient safety.

METHODS

We identified adverse and potential adverse events among a diverse group of diabetes patients who participated in an automated telephone health-IT self-management program via weekly interactions augmented by targeted nurse follow-up. We defined an adverse event (AE) as an injury that results from either medical management or patient self-management, and a potential adverse event (PotAE) as an unsafe state likely to lead to an event if it persists without intervention. We distinguished between incident, or new, and prevalent, or ongoing, events. We conducted a medical record review and present summary results for event characteristics including detection trigger, preventability, potential for amelioration, and primary care provider awareness.

RESULTS

Among the 111 patients, we identified 111 AEs and 153 PotAEs. Eleven percent of completed calls detected an event. Events were most frequently detected through health IT-facilitated triggers (158, 59%), followed by nurse elicitation (80, 30%), and patient callback requests (28, 11%). We detected more prevalent (68%) than incident (32%) events. The majority of events (93%) were categorized as preventable or ameliorable. Primary care providers were aware of only 13% of incident and 60% of prevalent events.

CONCLUSIONS

Surveillance via a telephone-based, health IT-facilitated self-management support program can detect AEs and PotAEs. Events detected were frequently unknown to primary providers, and the majority were preventable or ameliorable, suggesting that this between-visit surveillance, with appropriate system-level intervention, can improve patient safety for chronic disease patients.

Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals

OBJECTIVES

To assess the effectiveness of an intervention package comprising intense education, a range of reporting options, changes in report management and enhanced feedback, in order to improve incident-reporting rates and change the types of incidents reported.

DESIGN, SETTING AND PARTICIPANTS

Non-equivalent group controlled clinical trial involving medical and nursing staff working in 10 intervention and 10 control units in four major cities and two regional hospitals in South Australia.

MAIN OUTCOME MEASURES

Comparison of reporting rates by type of unit, profession, location of hospital, type of incident reported and reporting mechanism between baseline and study periods in control and intervention units.

RESULTS

The intervention resulted in significant improvement in reporting in inpatient areas (additional 60.3 reports/10,000 occupied bed days (OBDs); 95% CI 23.8 to 96.8, p<0.001) and in emergency departments (EDs) (additional 39.5 reports/10,000 ED attendances; 95% CI 17.0 to 62.0, p<0.001). More reports were generated (a) by doctors in EDs (additional 9.5 reports/10,000 ED attendances; 95% CI 2.2 to 16.8, p = 0.001); (b) by nurses in inpatient areas (additional 59.0 reports/10,000 OBDs; 95% CI 23.9 to 94.1, p<0.001) and (c) anonymously (additional 20.2 reports/10,000 OBDs and ED attendances combined; 95% CI 12.6 to 27.8, p<0.001). Compared with control units, the study resulted in more documentation, clinical management and aggression-related incidents in intervention units. In intervention units, more reports were submitted on one-page forms than via the call centre (1005 vs 264 reports, respectively).

CONCLUSIONS

A greater variety and number of incidents were reported by the intervention units during the study, with improved reporting by doctors from a low baseline. However, there was considerable heterogeneity between reporting rates in different types of units.

Medical malpractice and anesthesiology: literature review and role of the expert witness

PURPOSE

To provide a narrative review of the physician experience of medical malpractice litigation applied to an anesthesiology case with particular emphasis on the role played by medical expert witnesses.

SOURCES

Literature searches were conducted of English-language medical publications published between 1996 - 2006 using both Medline and Pubmed databases. Key words included: "medical malpractice"; "medical malpractice litigation"; "medical expert witness"; "expert witness liability", "expert witness bias"; "hindsight bias"; and "outcome bias".

PRINCIPAL FINDINGS

Patient injury resulting from medical care is common but most injured patients do not sue. Implicit review of medical files is biased to an important degree by the occurrence of severe injury; care is more often deemed substandard when the resulting injury is severe. Expert analysis of medical mal-occurrences is influenced by both hindsight and outcome bias. Compensation for those who do sue is influenced by the severity of injury and the degree of disability. The activity of experts is not commonly subject to review by peers, professional groups or licensing authorities.

CONCLUSIONS

The legal process for resolving patient claims against physicians is well delineated and transparent; its operational features are complex and prejudiced by severe outcomes. Bias is pervasive in the analysis of medical occurrences and may result in findings against caregivers which are unfair.

A multifacited approach to improve patient safety, prevent medical errors and resolve the professional liability crisis

The current professional liability crisis is the third in the last 30 years. Similarities of the 3 crises are the rising cost of professional liability insurance and a diminishing number of sources available to purchase coverage. Proposed tort reform with caps on noneconomic damages and attorney contingency fees is a back end approach and will do little to solve this crisis or prevent future ones. The current situation can only be solved by placing an increased emphasis on improving patient safety and elimination of all preventable medical errors. A national electronic medical record must be developed and rapid response teams need to be available in most hospitals. The protective devices of privileged communication and peer review are counterproductive and must be eliminated. Full and prompt disclosure of any medical error or injury needs to be made. Physicians must be taught proper communication skills and the importance of teamwork. Providers with frequent patient, nursing or medical staff complaints must be critically reviewed. The present system of risk management needs to move from a reactive position to a role of being proactive for both patient and physician. Claims management should offer the patient early compensation when appropriate and pursue a vigorous defense when medical care is adequate. Experts should be identified who will render fair, unbiased reviews of medical care with all of their findings being disclosed. Similar experts need to devise clear, concise, evidenced based standards of care for common medical conditions.