Coverys report shows areas at greatest need for clinical care improvement and risk management.
Surgeries and diagnoses generate the most medical malpractice claims, a recent report on a decade of malpractice data says.
Despite advances in patient safety since the publication of the landmark report To Err Is Human: Building a Safer Health System more than 20 years ago, medical errors continue to draw thousands of malpractice claims annually. The recent report, which was published by Coverys, says malpractice claims that the company handled over the past decade show the quest to improve patient safety is far from over.
"Change is not happening as quickly and collectively as it needs to. Our data shows improvement in select areas such as increased patient engagement, flattened hierarchies and the ability for staff at all levels to raise concerns, increased teamwork, and better sharing of information. However, many areas remain largely unchanged," the Coverys report says.
The report features data collected from more than 20,000 closed claims at Coverys from 2010 to 2019. The report includes several key data points.
- Average indemnity paid in malpractice claims increased from $342,581 in 2010 to $411,053 in 2019.
- The Top 5 malpractice allegations were surgery or procedure-related (29.2%), diagnosis-related (27.3%), medical treatment-related (12.5%), medication-related (8.8%), and patient environment safety (6.0%).
- The Top 5 complaints related to surgery and procedure events were surgical team performance (78.2%); retained object (7.1%); unnecessary surgeries (3.5%); wrong side, site, or patient (3.4%); and delayed surgery (2.7%).
- The Top 5 complaints related to diagnosis events were evaluation of patients including history and physical (32.0%), interpretation of tests (23.9%), ordering diagnostic or lab tests (23.5%), referral management (7.5%), and doctor follow-up with patients (5.0%).
- Most diagnosis-related events occurred in physician offices (34.6%) or emergency departments (24.9%).
- Cancer was the top medical condition for diagnosis-related events, at 28.5%.
"We were somewhat surprised and even disappointed that we did not see improvement in some of the key areas. Certainly, failure to diagnose and surgical error were areas that remained at high levels, with many of the same issues that we saw in the early days of patient safety improvement," Bob Hanscom, JD, vice president of business analysis at Coverys, told HealthLeaders.
Improving surgery and procedures
To improve surgery and procedures, healthcare organizations should focus on the top two risk management factors, technical skill and clinical judgement, Ann Lambrecht, RN, BSN, JD, a senior risk specialist at Coverys, told HealthLeaders.
"Embedded in clinical judgment are patient assessment and diagnosis of that clinical condition. Those factor very heavily in the clinical judgment. Evaluation of surgical outcomes with feedback provided to the practitioner is part of ongoing performance evaluation and that ongoing focus is critical in addressing technical skill and improving surgical outcomes. We think this is not always happening—it is not happening on a consistent basis and it is not happening periodically," she says.
Training and building experience also are important to improving surgery and procedures, she says. "Ongoing training and being able to perform a certain volume of procedures is essential to maintaining technical proficiency. In anything we do, the more we do it, the better we get at it and the less variation."
There are three primary ways to improve surgery and procedures, Hanscom says.
- Although surgical safety checklists were enthusiastically received in certain parts of the country and across Europe, they need to be implemented broadly across the United States.
- Technical skill has shown improvement and less variation when organizations have invested in simulation and skills labs, where surgeons can practice procedures and be safe in making mistakes.
- Health systems and hospitals need to make reducing distractions in operating rooms a priority.
Lambrecht says efforts to improve diagnosis should focus on the three top risk management categories: clinical judgment, clinical systems, and communication.
"Certainly, use of clinical decision support tools could assist in the clinical judgment arena—they help address issues of hidden bias and narrow diagnostic focus. Clear consultation policies that define when a consultation must occur and how consultants' findings are communicated add another layer to improve diagnostic accuracy. Finally, you should have a chain of command to escalate issues when differences in care arise," she says.
To improve diagnosis, healthcare organizations should address process variability and cognitive variability, Hanscom says.
"The standardization of processes that support high reliability and at least make sure that you are taking all of the steps to reach the right diagnosis is critical. It goes from the initial evaluation of the patient, all the way through to referral management and follow-up with patients. What is the process and how do we make sure things do not fall through the cracks?" he says.
Cognitive variability is significant because clinicians with less and less time on their hands succumb to their own biases, Hanscom says. "They think they know what the condition is and they are going after that—they are not necessarily doing the rule-outs that they were taught to do in medical school because they don't have time to do it."
Technology has a role to play in reducing cognitive variability in diagnosis, he says. "This is where innovation needs to step up in terms of bringing artificial intelligence to the decision-making process."
Improving the evaluation of patients—including patient history and physicals—is essential to achieving effective diagnoses, Lambrecht says.
"One key component is having an experienced provider conduct the initial evaluation that all future assessments will be compared to. This is seldomly done. Typically, it is a resident or an advanced practice provider who conducts the initial evaluation. So, when the initial assessment does not catch even a small issue, that one oversight can trigger a cascade of events that is very difficult to reverse," she says.
Patient engagement plays a crucial role in diagnosis, Hanscom says. "Patients should be participating. They should be reporting their symptoms in the most accurate way possible. They should be encouraged to ask questions. They should be talking about their family history. Patients need to be involved. That should carry through every step of the diagnostic process."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
According to Coverys data collected over the past decade, surgeries and procedures drew the highest number of medical malpractice allegations, at 29.2%.
Diagnoses drew the second highest number of malpractice allegations, at 27.3%.
Most diagnosis-related malpractice events occurred in physician offices (34.6%) or emergency departments (24.9%).