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Balancing Patient Safety and Tort Reform

While tort reform and liability costs dominate the concerns of physicians and other health care entities, the quality of healthcare in America is a “hot topic” and apprehension about patient safety paramount in the public’s mind. Numerous publications have appeared on the subject exemplified by the landmark reports of the Institute of Medicine beginning with the familiar “To Err is Human: Building a Safer Health System” in 1999 and several subsequent reports. However frustrating these reports, the abundance of data indicates we do have a problem.

Congressional hearings highlight patient fears; medical malpractice awards and medical liability insurance premiums are rising and medical journals publish numerous articles documenting and quantifying the risks of healthcare delivery. Numerous government and private sector organizations have convened panels and issued legislative or regulatory initiatives designed to document errors and start the search for solutions. Though physicians may view safety initiatives as bureaucratic intrusions on their everyday professional routines, most of these efforts are attempts to improve the delivery of effective, safe, patient-centered healthcare.

The majority of medical malpractice cases reflect repetitive events. The restlessness of the anesthetized patient is interpreted as a reaction to light anesthesia rather than a response to hypoxemia; the feverish and listless infant with a poor suck is treated in a routine manner and the diagnosis of meningitis is not considered; the 32-year old male with chest pain that is typical for an impending MI is treated for muscle strain because he is “too young” to have a heart attack, and the list goes on. These specific errors keep turning up year after year.

The Physician Insurers Association of America (PIAA) has been collecting medical malpractice claims data since 1985. Studies of nationwide malpractice claims and suits indicate that as many as 75% involve an allegation of failure to diagnose. According to the most recent cumulative data from PIAA the number one allegation against primary care physicians is errors in diagnosis of the medical conditions: myocardial infarction, breast cancer, appendicitis, colon cancer and lung cancer. Claims of failure to diagnose, if successfully pursued, can result in payments ranging from $50,000 to $2,000,000 or more. In cases involving an alleged neurologically damaged infant or adult the indemnity payment is often in the million dollars or higher range.

In failure to diagnose cases the documentation often does not show a consistent capture of risk-related clinical data. The documentation that a systematic search for the broader implications of the presenting complaint, such as exploration of suspicious historical leads related to atypical chest pain, for example, is missing. Contributing factors, in addition to incomplete documentation, include inadequate medical team communication, premature closure on assumed conditions without further exploration of symptoms or patient statements and a history or exam performed too briefly or hastily to pick up subtle signs of a high risk condition.

In many of these cases it is alleged that the information that could have assisted the physicians to make an accurate diagnosis was not obtained, communicated or documented. Premature diagnosis and/or treatment of the medical condition without additional investigation of symptoms or patient complaints, and a history or exam performed too briefly or hastily to pick up the subtle signs of a high risk condition are also alleged to have contributed to the adverse outcomes.

Researchers in the field of patient safety report that most medical errors cannot simply be prevented by perfecting individual physicians, nurses or pharmacists. Systemic cultural change is more productive in reducing medical errors than is targeting and punishing the individuals involved in patient care. Effective clinical care requires the collection, exchange and transfer of vast quantities of information between physicians, other members of the healthcare team and patients. Thus, improving the quality of healthcare involves the coordinated efforts of all members of the healthcare team with the understanding that information and communication are pivotal elements for the delivery of quality healthcare.

Until recently, the quality of healthcare and patient safety in the physician’s office was not adequately described since little research had been done and almost nothing had been reported in peer-reviewed literature. A recent article on this subject appeared in the New England Journal of Medicine. The study conducted by the RAND Corporation, reported that only 55% of studied patients received evidence-based, recommended care for 30 clinical conditions involving acute, chronic and preventive care. According to the lead researcher, Elizabeth McGlynn, “one of the reasons is that most physicians don’t take advantage of the latest technology to keep track of what they have done for their patients or share that information with other physicians and with the patients themselves.”

The RAND report says that the failure to do the right things extends across the spectrum of activities physicians are expected to perform. The quality of treatment differed markedly by disease, with the best performances seen in breast cancer, certain forms of heart disease and low back pain whereas less than one-half of the recommended best practices were followed for pneumonia, bladder infection, diabetes and peptic ulcers. The report states that “most of the time, the problem was that physicians or other healthcare practitioners did not do or ask enough.” Changes recommended by the study highlight the need for a more consistent use of information technology (IT) to track what has been done for the patient and remind the physician of what needs to be done.

Information gathering, sharing and documentation are crucial to an accurate diagnosis and implementation of a successful treatment plan. Whether or not you use electronic health records, there are some key strategies to assist you in your daily efforts to provide quality healthcare to your patients.

• Look at the record of the previous visit. It is particularly important when another physician or healthcare practitioner has previously evaluated the patient.
• Keep critical patient information at your fingertips. Essential patient information such as the patient’s current list of medications, medication allergies or reactions, and use of herbal and home remedies should be readily available when prescribing. This means critical patient information must be in the medication administration record by the physician’s side or flashing on the computer screen.
• Organize the minimum information such as age, weight, diagnosis, etc., in your paper or electronic chart. If everyone knows where to find the information, you’ve won half the battle. The other half is consistently capturing and updating the pertinent details.
• Designate a single spot in the chart so all team members can easily see the critical information necessary, such as allergies, when prescribing medication.
• ? Use lists. Make it easy to keep track of medications or unresolved healthcare issues. Add a preprinted list to your paper records. Add a “yes” or “no” checkbox next to the medication or unresolved issue to elicit patient input. Information should be updated at each office visit.
• ? Use shaded boxes that easily catch the eye to prevent accidentally overlooking inquiries about critical information. Review shaded boxes for documentation of critical information.

This information was taken from the MICA AudioRx CME program entitled: Management of Patient Information to Enhance Outcome © MICA 2004. For a copy of the CD and reference list, contact MICA Risk Management.