Access to primary care is becoming more challenging, in part due to physicians leaving the field. Twenty-nine states have expanded nurse practitioner (NP) autonomy to increase access. This study compares potentially inappropriate prescribing practices between NPs and primary care physicians (PCP). In the study population, adults aged 65 and older, NPs and PCPs had nearly identical rates of potentially inappropriate prescribing. The authors encourage focusing on improving prescribing practices among all prescribers instead of working to limit prescribing to physicians.

Error disclosure is critical to improving communication and patient safety. This article describes the development and pilot testing of the Medical Injury Reconciliation Experiences Survey (MIRES). The final 40-item survey addresses patient and/or family perceptions of communications with healthcare providers after the injury, perceptions of remedial gestures, overall satisfaction with the reconciliation process, the nature and impacts of the injury, and patient characteristics.

This systematic review synthesized evidence from 37 studies to examine the association between malpractice liability risk and healthcare quality and safety. The review found no evidence of association between liability risk and avoidable hospitalizations or readmissions, and limited evidence supporting an association between risk and mortality (5/20 studies) or patient safety indicators or postoperative complications (2/6 studies).

Confidential skill assessments have been recommended as a strategy to ensure competence among aging surgeons. In this qualitative study, the authors describe opinions from 52 experts on how to manage potential concerns associated with aging surgeons.

Patient engagement is now acknowledged as a cornerstone of patient safety, but the perspectives of patients who have experienced adverse events remain understudied. This interview study of 92 patients who had experienced iatrogenic injury identified several insights about the aftermath of adverse events. As with prior studies, researchers found that patients expressed a desire to be heard. Participants had positive perceptions of patient safety research and expressed a desire that others learn from the adverse event they experienced. The authors suggest that institutional review boards permit investigators to approach patients who have experienced adverse events to participate in studies, rather than prohibit such studies due to fear of causing further psychological harm. They also recommend that researchers discuss these adverse events with patients through a reciprocal lens, expressing support and sympathy rather than maintaining an emotionally distant stance. A previous PSNet interview with the lead author discussed disclosure and apology in health care.

Malpractice claims can shed light on patient safety hazards. This observational study examined how paid malpractice claims affected physicians' practice. Investigators found that a small proportion of physicians, about 10%, had one or more paid malpractice claims, consistent with prior studies. Approximately 2% of physicians accounted for nearly 40% of paid claims. Physicians with paid claims were more likely to leave clinical practice and more likely to move to smaller practice settings. The authors raise the concern that physicians who move to smaller practice settings may lack the institutional and peer support to remediate their clinical skills and behavior. A PSNet perspective explored the risk of recurring medicolegal events among providers who have received multiple malpractice claims.

Communication-and-resolution programs have demonstrated declines in malpractice claims in early studies, but implementing these programs effectively has been a challenge. This study is the first to examine patient perspectives on communication-and-resolution programs. Investigators interviewed 30 patients, most of whom experienced harm. Respondents expressed a desire for providers to listen to their perspectives without interruptions, consistent with prior studies. Although patients wished for information regarding what hospitals planned to do to prevent similar events in the future, most reported that they did not receive such follow-up. The authors state that their findings represent opportunities to improve communication-and-resolution programs. A past PSNet interview discussed an organization's pioneering efforts to implement a communication-and-response system.

This review explores policy and legal approaches to addressing care delivery problems, including strategies that focus on transparency, reimbursement, professional regulation, and tort reform. The authors suggest cardiologists are well-positioned as leaders in adopting these approaches because the conditions they treat are highly visible, common, and expensive.

A growing body of research has begun to assess the role of individual clinicians in patient safety, seeking to identify clinicians whose patients are at elevated risk of adverse events. Examining data on paid malpractice claims from the National Practitioner Data Bank over a 10-year period, this study found that 1% of physicians accounted for 32% of paid claims. Moreover, recidivism was common, in that practitioners with more than 3 claims had a 24% risk of another claim within the next 2 years. As in prior studies of malpractice data, surgeons and obstetricians were more likely to have paid a claim than internists. The pattern of a relatively small number of physicians incurring repeated claims, which mirrors data from studies of patient complaints, implies that it may be possible to identify clinicians who are at high risk of subsequent malpractice claims or patient complaints. The issues around such high-risk physicians are discussed in a previous WebM&M perspective.

Past studies have found a correlation between patient complaints and patient safety problems. Researchers sought to identify physicians at highest risk for a second patient complaint using routinely collected administrative data. They developed a risk prediction model which predicted future complaints with reasonable accuracy. Factors such as procedural specialty, male gender, and time since prior complaint were associated with a subsequent patient complaint. Application of this model has the potential to allow real-time identification of physicians at risk for further patient complaints and possible litigation. Actions to reduce future litigation risk—such as directed education, referral to a regulatory agency, or notification of the risk of future complaints—could be appropriately targeted based on this prediction model. A related editorial urges prompt and rigorous investigation of patient complaints.

This review of national trends in medical malpractice claims explores the current environment, in which there has been a declining rate of paid claims as well as decreasing or flat compensation amounts. The authors discuss alternative approaches to malpractice. They predict the expansion of communication-and-resolution programs, where providers and health systems disclose errors, apologize, and offer compensation to patients and families if appropriate. The authors also expect that pre-suit notification (requiring patients and families to inform providers of intent to sue), apology laws (dictating that statements of fault or regret cannot be used in malpractice claims), and administrative compensation systems (which use an adjudication process rather than usual courts) will all play a larger role and lead to more rapid resolution following adverse events. They advocate for safe harbor legislation which would permit providers to use adherence to a clinical guideline as a defense. Formation of accountable care organizations may lead to reform in the liability system such that organizations rather than individuals are liable for malpractice. This data not only serves to underscore the shortcomings of the current malpractice environment in promoting patient safety, but suggests how alternative approaches might better serve all parties.

This qualitative study found that most health care leaders believe that board members have opportunities to influence quality and safety. However, insufficient knowledge, experience, and performance measurement may hinder board engagement in quality and safety, and these barriers may contribute to deficiencies in performance.

… disclosure across institutions. In a past AHRQ WebM&M perspective , Dr. Albert Wu discussed the importance of …

Although most patient safety efforts focus on identifying and addressing flawed systems, individual clinicians who cause recurrent problems—either through substandard clinical performance or overtly disruptive behavior—must be addressed as well. This analysis of an Australian national database revealed that just 3% of physicians accounted for nearly half of all complaints filed by patients, and relatively simple characteristics (including physician gender, clinical specialty, and number of prior complaints) predicted the likelihood that an individual clinician would be the subject of future complaints. These data, combined with prior research connecting medical school behavior to the risk of future disciplinary action, provide a means for regulatory authorities to predict problematic behavior by clinicians and point the way toward system-level solutions for problem doctors.

This commentary outlines a service recovery model to help providers communicate effectively with patients and their families after an adverse event.

This study analyzed 56 missed or delayed cancer diagnoses and found that virtually all cases involved cognitive errors and half involved logistical breakdowns.

This study of the outcomes of patient complaints in Australia found evidence of an expectations gap, as patients' requests for compensation or corrective actions were fulfilled in only a minority of cases.

This piece discusses the no-fault medical injury compensation programs of Denmark, Sweden, and New Zealand and explores how elements of these programs can be applied to compensation efforts in the United States.