Toward Preventing Medical Malpractice Claims Related to Chest Procedures

Procedural Competency Among Hospitalists: A Literature Review and Future Considerations

BACKGROUND

As general internists practicing in the inpatient setting, hospitalists at many institutions are expected to perform invasive bedside procedures, as defined by professional standards. In reality, hospitalists are doing fewer procedures and increasingly are referring to specialists, which threatens their ability to maintain procedural skills. The discrepancy between expectations and reality, especially when hospitalists may be fully credentialed to perform procedures, poses significant risks to patients because of morbidity and mortality associated with complications, some of which derive from practitioner inexperience.

METHODS

We performed a structured search of the peer-reviewed literature to identify articles focused on hospitalists performing procedures.

RESULTS

Our synthesis of the literature characterizes contributors to hospitalists' procedural competency and discusses: (1) temporal trends for procedures performed by hospitalists and their associated referral patterns, (2) data comparing use and clinical outcomes of procedures performed by hospitalists compared with specialists, (3) the lack of nationwide standardization of hospitalist procedural training and credentialing, and (4) the role of medical procedure services, although limited in supportive evidence, in concentrating procedural skill and mitigating risk in the hands of a few well-trained hospitalists.

CONCLUSION

We conclude with recommendations for hospital medicine groups to ensure the safety of hospitalized patients undergoing bedside procedures.

Characteristics of medical malpractice claims involving emergency medicine physicians

BACKGROUND

Identifying characteristics of malpractice claims involving emergency medicine (EM) physicians allows leaders to develop patient safety initiatives to prevent future harm events.

METHODS

A retrospective study was performed of paid/unpaid claims closed 2007 to 2016 from Comparative Benchmarking System. Claims were identified by physician specialty involved (EM, internal medicine, general surgery). Various characteristics were compared by physician specialty. Multivariable regression was performed to identify factors associated with claim payment, in which (1) physician specialty was included as a predictor and (2) only the subset involving EM physicians was analyzed.

RESULTS

Of 54,772 claims, 2760 involved EM physicians, 5886 involved internists, and 3207 involved surgeons. Death was the most common severity among EM claims (34%). Diagnosis-related allegations accounted for 58%, higher than 42% and 11% of claims involving internists and surgeons, respectively (P < 0.0001). Thirty-one percent was paid. The median indemnity paid on behalf of any defendant was $206,261 (interquartile range $55,065-527,651). The most common final diagnoses were myocardial infarction (2%), pulmonary embolus (2%), and cardiac arrest (2%). Procedure-related claims were associated with increased payment likelihood (odds ratio 1.21, 95% confidence interval 1.10-1.34).

CONCLUSION

Malpractice claims in EM are often diagnosis- or procedure related. Our findings suggest that diagnostic accuracy and procedural competency should shape future quality improvement work.

Medical Malpractice Claims Involving Physicians in the Intensive Care Unit: A Cohort Study

BACKGROUND

The intensive care unit (ICU) is a fast-paced setting, in which physicians from different specialties work. The goal of this study is to understand whether characteristics of medical malpractice claims occurring in the ICU differ by physician specialty.

METHODS

A retrospective cohort study was performed using a national database called the Comparative Benchmarking System, which is operated by Harvard's malpractice insurer. Claims were included if the harm events occurred in the ICU and closed between 2007-2016. Claims were analyzed according to physician specialty of the "primary responsible provider," which was the physician most directly involved in the harm event. Patient-, provider- and claim-level characteristics were compared among the 6 most common physician specialties that were identified as "primary responsible provider." Multivariable regression was performed to identify factors associated with claim payment.

RESULTS

Of 54,772 claims, 1,113 resulted from harm events in the ICU, of which 843 involved the following physician specialties: internal medicine (305), cardiology (163), pulmonary medicine (149), general surgery (98), neurology (97) and anesthesia (31). The minority of claims across physician specialties originated in academic medical centers (<30%). The most common severity of harm was death (Range 42-72%, P = 0.0001). The frequency with which claims involved procedures varied by physician specialty (Range 24-84%, P < 0.0001). The 3 most common contributing factors (patient assessment, selection/management of therapies and communication among providers) did not differ by physician specialty. In multivariable regression, claims that were procedure-related were statistically more likely to result in payment (Odds Ratio 2.29, 95% Confidence Interval 1.64-3.20), after adjusting for physician specialty.

CONCLUSIONS

There were few unexpected differences in malpractice claims occurring in the ICU by physician specialty. Prevention efforts could focus on procedures, regardless of physician specialty, including: 1) maintaining procedural skills, 2) framing procedural risks well and 3) accurately describing procedural complications after they happen.