Narrowing the Focus for Patient Safety By John L. Mc Carthy Jack Mc Carthy is President of CRICO/RMF.

Medical malpractice cases are often filed after outcomes have not matched what patients expected. While it is true that some of these events have such unusual attributes that it is difficult to find anything “teachable,” a much greater number of these cases provide informative snapshots of where processes, systems, and sometimes individual behaviors have truly failed the patient or the patient’s family. Conversely, the care may have met professional standards, but an unexpected outcome was exacerbated by poor communication, leading to a decision to sue for malpractice.

Each year, 200 to 300 patients file malpractice claims and suits against CRICO-insured providers. Across the country the number approaches 90,000 cases annually.¹ While each case has unique attributes, experts are gaining insight by looking at cases as symptoms of a larger problem, not as isolated events. Quite often, the providers named in a claim or suit were just one part of a system that failed to support optimal care or reconcile errors.

The Nagging Questions

The events retold in these examples are, by definition, unexpected. The nagging questions challenging patient safety experts and others seeking to reduce patient injuries are “What can we predict, what can we prevent, and what systems can we build to interrupt and counterbalance those errors we can neither predict nor prevent?” Unfortunately, even the most diligent efforts cannot pinpoint precisely when and to whom an adverse outcome will occur. The wide range of total patient-clinician encounters hinders attempts to detect the (very) few particular events that will lead to unnecessary harm. Nevertheless, that is the challenge CRICO/RMF has taken on. With nearly 30 years of clinical observation, data collection, and expert analysis, CRICO/RMF has the raw materials for narrowing the focus of patient safety initiatives. The most potentially fruitful source is recently filed malpractice cases associated with severe injuries or death (high-severity cases). Two significant reasons for focusing on this subset of cases are: 1) high-severity cases will likely lead to the most efficient reduction of all types of patient injuries, and 2) plaintiffs’ attorneys are more posed to pursue high-severity cases that they perceive as more winnable and profitable.

Finding Commonalities

The first step in CRICO/RMF’s effort to narrow the focus for patient safety was to distinguish the broad categories. Four “target” areas constitute two-thirds of the high-risk patient encounters where CRICO/RMF is now focusing programs and initiatives. The cases within these target areas offer solid footing for beginning more detailed analysis. They also reveal patient safety risks common across the full range of case categories.
The second step involved analyzing the cases within each target area to pinpoint the factors common to a significant percent of cases. What “types” of surgery-related cases (or obstetrics-related, etc.) recur and what makes them similar? Is there a certain type of patient who gets hurt; is there a certain type who files a lawsuit? Do clinicians who get sued demonstrate specific behavioral traits; is there a susceptible bedside manner? Do events that lead to patient harm (that then lead to claims and suits) occur in particular settings; do they really occur late at night and on weekends? Do some drugs get misprescribed, or misadministered, more than others? Does a left-handed surgeon encounter risks her right-handed peers don’t?

Initial analysis of the high-severity cases led to more precise questions in each category. The third step in narrowing the focus of patient safety efforts and directing resources was to initiate a dialogue with researchers and clinical leaders. The data, studies, analysis, and the claims themselves became the basis for action. For example:

• When an analysis of obstetrics-related cases indicated that many errors could have been prevented by better teamwork, CRICO/RMF put its support behind a project to see how teamwork training in labor and delivery units could reduce such errors.²
• The discovery that mismanagement of patients on anticoagulant therapy was a common factor in medication cases drove efforts to develop safer systems for patients on Coumadin therapy.
• A human factors engineering study of operating room behavior sponsored through CRICO/RMF has identified pre-surgery briefings as an improvement opportunity.³
• After understanding that malpractice cases alleging a delay in the diagnosis of colorectal cancer often involved missteps in assessing and stratifying the patient’s risk, CRICO/RMF coordinated development of an algorithm to help clinicians and patients better understand the risks and to aid the screening decisions.⁴

Keeping Focus on a Changing Picture

The big picture of what patient safety should look like changes along with clinical discoveries and innovations. Maintaining a focus on this moving target requires both vigilance and flexibility. The glint of new risks can distract resources from unfinished business. On the other hand, an effective solution to a significant risk is often an opportunity to free up resources to address other concerns.
To keep pace, CRICO/RMF continues to work with health care entities to collect and analyze error-related information, while digging deeper within the malpractice claims files to code the data based on systems issues. At the same time, CRICO/RMF looks to patient safety directors and researchers to direct the study of error-related information from near-miss events, which are more frequent and more current than malpractice claims and suits.⁵

Putting Our Money Where Our Mouth Is

Crico premiums have continued to be stable in the New England area. Financial resources derived from savings on claims costs are being re-directed into patient safety and research. For each of the past three years, the CRICO Board has allocated $500,000 for patient safety research, resulting in an impressive array of high-impact safety studies. Premium incentives have been established for anesthesiologists and for obstetricians who participate in simulation and team training. These efforts and many others cost 5–10 percent of total premium, but everyone involved, from insured physicians to board members, has expressed a willingness to make the necessary investments in patient safety. The results of these efforts are beginning to speak for themselves.

Notes and References

1. National Association of Insurance Commissioners
2. Evaluation of the MedTeams Intervention in Labor and Delivery Care, coordinated by Benjamin Sachs, MD, Obstetrician-Gynecologist in Chief, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
3. Roth EM, et al. Using field observations as a tool for discovery: analyzing cognitive and collaborative demands in the operating room. Cognition, Technology & Work 2004;6(3):148-57.
4. RMF Colorectal Cancer Screening Algorithm: a decision support tool for primary care providers. www.rmf.harvard.edu/reference/guidelines/colorectal/RMFCRC.pdf
5. A malpractice claim or suit need not be filed for up to three years from the date of loss—or discovery of loss—and up to seven years for minors. In some instances, by the time the case details can be captured, coded, and analyzed, more than 10 years has passed since the precipitating event occurred. Potential sources for more timely error information are: incident/near miss reports, online reporting data, root cause analyses, and patient complaints that are already compiled by individual institutions.