Director's Forum

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Patient Safety and Loss Prevention—Part I

by David B. Troxel, M.D., Board of Governors

Risk management has played an important role in both the institutional and office practice of American medicine since the 1970s. With the new millennium, however, the focus has shifted from loss prevention to patient safety, and the advancement of patient safety has become a national priority—for physicians, government, industry, third-party payers, and patients alike.

The patient safety movement is an outgrowth of the 1999 Institute of Medicine monograph To Err Is Human. One of the report’s conclusions is that medical error results from faulty systems, not from the carelessness of individuals––thus patient safety strategies focus on system failures as the prime cause of patient injury, NOT human error.

The major players in the patient safety movement are The Leapfrog Group (composed of 160 major companies that purchase health care for their employees); the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); the National Patient Safety Foundation (sponsored by the American Medical Association, among others), which is committed to supporting and promoting the patient safety movement through education, research, and the promotion of a health care culture of patient safety; and the Institute of Medicine.

The Leapfrog Group promotes patient safety by setting health system standards for hospitals (“leaps” in quality and safety), surveying for compliance, and then making its survey results public to help consumers make informed choices. Its current standards include:

• Promoting the use of computers to order medications, tests, and procedures in order to reduce entry errors
• Publishing outcome data (complication and survival rates) for hospitals that meet process and volume criteria for high-risk surgical procedures and deliveries
• Promoting ICU staffing by board-certified “intensivists”
• Publishing a hospital-specific “Quality Index” based on implementing 27 procedures to reduce medical mistakes

The JCAHO’s National Patient Safety Goals for 2005 include:

• Improving the accuracy of patient identification
• Improving the effectiveness of communication
• Improving the safety of using medications
• Eliminating wrong-site/wrong-patient/wrong-procedure surgery
• Improving the safety of infusion pumps and alarm systems
• Reducing health care–associated infections
• Reducing injury from patient falls
• Reducing the risk of influenza and pneumococcal infection in elderly patients
• Reducing the risk of surgical fires

Risk management programs that many professional liability insurance companies provide include:

• Identifying recurrent patterns of medical error and patient injury through expert medical review of claims in each specialty
• Using that data to develop general and specialty-specific educational risk management strategies to eliminate or reduce the incidence of adverse medical outcomes
• Developing risk management publications covering professional conduct, medical record documentation, informed consent, physician-patient communication, and practice guidelines
• Developing risk management bulletins to provide timely alerts and loss prevention information for emerging treatments, procedures, and drugs
• Performing site surveys to evaluate practice locations, educate office staff about liability issues, and review medical records
• Providing risk management assistance via an 800 “hotline” number
• Publishing risk management newsletters, disseminating clinical guidelines, and providing patient education materials
• Providing updates on legislative, regulatory, and tort reform issues

It is obvious that there is considerable overlap between the system-failure focus of the patient safety movement and the human-error focus of risk management as causes of patient injury. Of course, risk management is also about loss prevention, i.e., managing the risk of medical liability for both the insured physician and his or her insurer. For these reasons, it seems appropriate to combine the principles of risk management with the systems orientation of patient safety to create a new program focusing on “Patient Safety and Loss Prevention.”

The U.S. judicial system defines medical malpractice as injury resulting from negligence. Negligence is defined by expert testimony as medical practice that falls below the standard of care. Standard of care is the professional behavior expected of a prudent, careful, and informed physician; it is a national standard, not a community standard, and is increasingly difficult to differentiate from “best practices.” Finally, the injury must be a consequence of negligent professional behavior; i.e., there must be both negligence and causation.

In reality, only 5 percent of claims go to trial, and the defendant doctor wins 80 percent of these in court. Another 75 percent of medical liability claims are dismissed or dropped. The remaining 20 percent of claims are settled—and many of these claims are considered medically defensible but are difficult to defend due to legal (not medical) considerations.

While loss prevention programs promote patient safety by identifying potential sources of patient injury, they also uncover factors that cause claims to become legally compromised. These need to be managed so that medically defensible claims can be defended in court or settled on favorable terms.

A common sequence of events leading to a malpractice claim is as follows:

• An unanticipated medical event, complication, or outcome
• Patient surprise
• Physician denial
• Communication breakdown
• Doctor-patient relationship breakdown
• Patient anger
• Patient contacts a lawyer

Loss prevention strategies designed to prevent these events include:

• Improving physician communication skills
• Accepting responsibility for unexpected medical events or outcomes—and learning to say “I’m Sorry” without admitting negligence or fault
• Improving the informed-consent process and educating patients about their medical condition
• Maintaining well-documented medical records
• Assuring follow-up of laboratory and imaging studies
• Coordinating medical care and assuring appropriate follow-up

Each of these strategies will be subsequently explored in detail in “Patient Safety and Loss Prevention—Part II.”

Patient Safety Resources

Institute of Medicine:
www.iom.edu

Joint Commission on Accreditation of Healthcare Organizations:
www.jcaho.org

The Leapfrog Group:
www.leapfroggroup.org

National Patient Safety Foundation:
www.npsf.org
 

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