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Search results for "Active Errors"

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Journal Article > Commentary

The Sorry Works! Coalition: making the case for full disclosure.

Wojcieszak D, Banja J, Houk C. Jt Comm J Qual Patient Saf. 2006;32:344-350.

The authors describe the work of The Sorry Works! Coalition, which aims to minimize the stress and cost associated with medical error by promoting full disclosure and apology.

Journal Article > Study

Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992–2014.

Schaffer AC, Jena AB, Seabury SA, Singh H, Chalasani V, Kachalia A. JAMA Intern Med. 2017;177:710-718.

This retrospective study of a claims database found that medical malpractice claims declined significantly between 1992 and 2014, but mean payment amounts increased at the same time. Diagnostic error was the overall most common reason for a claim, affirming the importance of improving diagnosis.

Cases & Commentaries

Complaints as Safety Surveillance

  • Web M&M

Jennifer Morris and Marie Bismark, MD; September 2016

Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.

Journal Article > Study

Decreasing malpractice claims by reducing preventable perinatal harm.

Riley W, Meredith LW, Price R, et al. Health Serv Res. 2016;51(suppl 3):2453-2471.

Improving patient safety provides an opportunity to reduce malpractice claims and associated costs, particularly in higher risk clinical areas such as obstetrics. This study examined medical malpractice claims and cost data in the perinatal units of hospitals before and after implementation of safety interventions focused on decreasing perinatal harm. Interventions consisted largely of standardizing best practices and implementing team training. Investigators found that improving perinatal safety led to substantial reductions in both the frequency and total cost of malpractice claims. The role that the medical liability system plays in driving up health care costs and in promoting the practice of defensive medicine—which can lead to adverse events through unnecessary tests and procedures—was highlighted in a past WebM&M commentary.

Book/Report

Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report.

Cambridge, MA: CRICO Strategies; 2016.

Communication failures are known to contribute to medical errors. Analyzing more than 7000 cases in which communication breakdowns led to patient harm, this report explores selected specialties where such failures occur and discusses opportunities to improve information sharing among health care providers.

Book/Report

2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process.

Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.

This analysis of more than 4700 diagnosis-related malpractice claims found that most errors occur in the ambulatory setting, involve lapses in clinical judgement, and result in missed diagnosis of cancer. The authors use the data to explore cognitive and process failures that contributed to diagnostic errors.

Journal Article > Commentary

Unintended side effects: arbitration and the deterrence of medical error.

Shieh D. N Y Univ Law Rev. 2014;89:1806-1835.

This commentary explores the role of medical malpractice arbitration as a deterrent to medical error. The author suggests that although shifting from litigation to arbitration could result in improved efficiency and accuracy regarding medical malpractice litigation, it is not proven as a strategy to deter error. The discussion draws from the experience of a large health care system to recommend modifications in the arbitration process to prevent medical error.

Journal Article > Commentary

The medical liability climate and prospects for reform.

Mello MM, Studdert DM, Kachalia A. JAMA. 2014;312:2146-2155.

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.

Journal Article > Study

Characteristics of medical professional liability claims against internists.

Mangalmurti SS, Harold JG, Parikh P, Flannery FT, Oetgen WJ. JAMA Intern Med. 2014;174:993-995.

This analysis of closed malpractice cases against internal medicine physicians identified common causes for claims and associated outcomes. The authors found that 25% of malpractice cases resulted in payout, and diagnostic errors led to the most claims.

Journal Article > Study

Mandatory presuit mediation: 5-year results of a medical malpractice resolution program.

Jenkins RC, Smillov AE, Goodwin MA. J Healthc Risk Manag. 2014;33:15-22.

A mandatory mediation program for patients who experienced adverse events resulted in faster resolution of claims, lowered legal expenses for the health system, and greater compensation for patients judged to have meritorious claims. This approach may complement disclosure-and-resolution programs that also seek to streamline the error compensation process and improve its fairness.

Journal Article > Study

Enhance patient safety by identifying and minimizing risk exposures affecting nurse practitioner practice.

Leigh J, Flynn J. J Healthc Risk Manag. 2013;33:27-35.

This study analyzed 200 closed malpractice claims filed against nurse practitioners and found that most of the claims involved missed or delayed diagnoses.

Journal Article > Study

Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis.

Rubin JB, Bishop TF. BMJ Open. 2013;3:e002985.

This analysis of paid malpractice claims from the National Practitioner Data Bank found that the vast majority of claims were settled without a trial. The small number that did go to trial disproportionately involved physicians with prior malpractice claims.

Book/Report

Economic Analysis of Medical Malpractice Liability and Its Reform.

Arlen J. New York, NY: New York University School of Law; May 9, 2013. Public Law Research Paper No. 13-25.

This report describes a malpractice liability model to incentivize increased focus on preventing medical errors and reducing costs.

Journal Article > Study

25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank.

Saber-Tehrani AS, Lee HW, Mathews SC, et al. BMJ Qual Saf. 2013;22:672-680.

The patient safety consequences of diagnostic errors have been receiving greater attention in the past few years, after being relatively neglected in the early period of the safety movement. The results of this study will likely add momentum to this "next frontier" in patient safety. The authors analyzed 25 years of closed malpractice claims from the National Practitioner Data Bank and found that diagnostic errors—primarily in the outpatient setting—were both the most common and the most costly (in terms of total payments) type of claim. Compared with other types of errors, diagnostic errors were more likely to result in serious patient harm or death. Although data from closed malpractice claims may not be representative of all error types, it is clear from this study that diagnostic errors account for a large proportion of preventable patient harm. Recent reviews have identified strategies to improve diagnostic accuracy at the individual clinician level and at the system level. The human costs of a fatal diagnostic error—for the patient and the clinician—were vividly illustrated in a recent graphic-novel style article.

Newspaper/Magazine Article

Medical malpractice: why is it so hard for doctors to apologize?

Sanghavi D. Boston Globe Magazine. January 27, 2013.

Discussing barriers to physician error disclosure, this article details how an apology-and-offer approach and analyzing claims data can improve transparency and health care safety.

Journal Article > Commentary

Should medical malpractice prevention be considered separately or as an integral part of comprehensive health care safety improvement?

Enbom JA. Am J Obstet Gynecol. 2013;208:495-498.

Exploring the relationship between liability payments and patient safety, this commentary recommends that the concepts be combined to inform and drive improvement.

Journal Article > Study

Disclosure-and-resolution programs that include generous compensation offers may prompt a complex patient response.

  • Classic

Murtagh L, Gallagher TH, Andrew P, Mello MM. Health Aff (Millwood). 2012;31:2681-2689.

Some institutions have implemented disclosure-and-resolution programs whenever an error occurs, in which the error is fully disclosed to patients, the clinician apologizes, and financial compensation is offered when appropriate. Early data indicates that this approach may reduce malpractice lawsuits, and another survey found that patients who had confidence that their physicians would appropriately disclose errors were less likely to sue. However, this vignette-based survey study found that offering full financial compensation to patients after errors actually increased mistrust between patients and clinicians and increased the likelihood that a patient would seek legal advice, even though most patients desired some form of compensation. The authors conclude that institutions should consider separating error disclosure and offers of compensation in order to minimize the perception of conflict of interest.

Special or Theme Issue

Errors and Malpractice in Radiology.

Pinto A, ed. Semin Ultrasound CT MR. 2012;33:273-382.

This special issue discusses radiology errors, including those that contribute to missed diagnosis of lung cancer and breast cancer.

Newspaper/Magazine Article

The short life and lonely death of Sabrina Seelig.

Hartocollis A. New York Times. July 28, 2012.

This newspaper article reports on the missteps that contributed to the death of a young woman after she was hospitalized in an incident reminiscent of Libby Zion.

Journal Article > Review

The spectrum of medical errors: when patients sue.

Kels BD, Grant-Kels JM. Int J Gen Med. 2012;5:613-619.

Examining cases of medical error and malpractice, this review details strategies to improve safety in health care.

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