2011 Annual Benchmarking Report - CRICO/media/Files/_Global/KC/PDFs/crico... · crico Strategies is pleased to present Malpractice Risks in Emergency Medicine, our third Annual Benchmarking

2011

Annual Benchmarking ReportMalpractice Risks in Emergency Medicine

Which scenario presents the greatest risk in your ED?

1

3

2

4 Psychiatric patient with potential to cause harm or significant disruption to the department?

Unstable trauma patient with life-threatening injuries?

Patient with non-specific chest pain?

Stable, boarding patient with diagnosis of arrhythmia being admitted to cardiac floor?

At a Glance...About four of every 100,000 ED visits result in an allegation of malpractice.

47% of ED cases allege a failure to diagnose.

39% of ED cases alleging a missed diagnosis cite a judgment error related to ordering a test or image.

41% of diagnosis-related ED cases involve inadequate assessment leading to premature discharge.

Community hospital-based nurses are named twice as frequently in ED malpractice cases as are nurses in academic medical centers.

Medical malpractice indemnity costs approximately $8 per ED visit.

crico Strategies is pleased to present Malpractice Risks in Emergency Medicine, our third Annual Benchmarking Report.

Even as the health care landscape changes, the pressure to care for patients with myriad needs remains the same for Emergency Medicine. In the Emergency Department (ED) setting, ongoing development of systems to support accurate diagnostic decision-making and effective communication are paramount. Otherwise patients suffer and providers face the consequences. According to our study of more than 90 hospitals across the country, about four of every 100,000 ED visits result in an allegation of malpractice. This, as we have learned over decades of patient safety risk analysis, represents only the tip of the adverse event iceberg.

Against this high-stakes background, CRICO Strategies and its partners continue to employ data from malpractice claims and other risk signals in a unique capacity to uncover your vulnerabilities. At the same time, we engage our community of peers to identify targeted solutions to help you improve the safety of care delivered in your EDs.

This year’s Report provides an in-depth exploration of the most pressing risks in Emergency Medicine based on data mined from Strategies’ Comparative Benchmarking System (CBS). This database of 200,000 medical malpractice claims and suits enables us to identify clinical trends, share poignant examples, and pinpoint learning opportunities. By providing credible insight, we hope this Report helps you guide your Emergency Medicine patient safety efforts toward fundamental, and truly effective change where it is needed most.

We hope that, as you evaluate your Emergency Medicine landscape, our findings help you identify signals of risk in your own systems. The data and conclusions in this Report provide a platform from which you can direct your insurer (or insureds) to the most pressing vulnerabilities.

As you consider how to translate our Report into opportunities for action to reduce risk and improve patient safety in your ED, please send us your comments and reflections, or call for more details. My colleagues and I look forward to collaborating with you—by sharing data, insight, and solutions—to improve the safety of care delivered at your organization.

RobeRt HanscomSenior Vice Presidentcrico Strategies

From 2006–2010, eight percent of all medical malpractice cases involved patients seeking treatment in an ED. Plaintiffs most commonly alleged a missed or delayed diagnosis (47 percent), and the majority of those led to permanent injury or death. The average payment for a case alleging a diagnostic error in the ED was $508,000; for the most severe cases, the average payment exceeded $650,000.

With most patients, Emergency Medicine physicians have no established relationship, and only limited context for the immediate complaint. Those factors inhibit obtaining a big picture perspective. For the ED staff, effective communication is critical to determining what you need to know “right now.” Keeping pace as new information unfolds amidst the chaos of multiple patients with unique narratives is essential to avoiding patient harm and an allegation of malpractice.

Even a smoothly functioning ED team can be impeded by the setting’s unique communication challenges. Comprehending a patient’s history

may be complicated by a language barrier or incompatible computer systems. Tracking a patient’s status over several hours is reliant upon a transient cast of physicians, nurses, physician assistants, technicians, and others gathering, documenting, and sharing noteworthy changes and milestones. Discharging an ED patient supposes a confidence that any life threats have been ruled out, his primary complaint has been understood, and he has been appropriately transitioned to the next stage of his care.

Emergency Medicine providers train to be prepared for whatever comes next without ever knowing who’s next. Nevertheless, multiple caregivers keeping pace with multiple patients, learning their stories, tracking tests and procedures, and sharing that information with colleagues are vulnerable to the risk of not having the right information at the right time. And that risk increases under the pressures of volume, distraction, fatigue, etc. If those communication gaps impact clinical judgment, a diagnosis may be missed or delayed, and compensation sought.

An ED pulses with the randomness of the next encounter. From traumas to the tedium of another sore throat, the unbroken flow of familiar uncertainty is both rewarding and risky.

Translating data from seemingly unique cases into a clinical process that triggers an awareness of clinical vulnerabilities is what brings these stories to life. Coupling this with benchmarking data that demonstrates the significance of our vulnerabilities as compared with the rest of the world has made all the difference in engaging our providers in improvement efforts.Larry smith, MedStar Health

cRIco stRategIes 2011 CBS: EmErgEnCy 3

Emergency Medicine has evolved into a highly demanding field: physically, intellectually, and emotionally. Ambulatory patients receive drugs and therapies formerly reserved for inpatients, and are presenting to the ed with an ever-growing array of crises. Emergency physicians are under pressure to decrease use of costly imaging and diagnostic support with—of course—zero tolerance for errors in our diagnosis, treatment, and disposition decisions. It is a daunting challenge.Ron m. Walls, mD Brigham and Women’s Hospital Boston

How often do Emergency Department patients sue?

$ 508 K average indemnity paid in diagnosis-related ed cases

$ 213 K average indemnity paid in other ed cases

ED cases involving diagnostic failures cost more.

8

6

4

2

02006 2007 2008 2009 2010

academic medical center

community hospital

6.7

7.66.9

5.65.0

ca

se

s p

er

10

0k

ed

vis

its

3.63.3

3.9

2.93.3

Diagnostic errors are the most common— and costly—allegation in ED cases.

top allegations cases filed indemnity incurred

percent of category

missed or delayed diagnosis 47 % 62 %

management of medical treatment 28 % 24 %

medication-related 7 % 4 %

safety or security 6 % 2 %

surgical treatment 3 % 3 %

4 cRIco stRategIes 2011 CBS: EmErgEnCy

Patients expect your team to share information vital to their care. They assume that the doctor who is asking questions at noon knows what they told the nurse at 9:30 a.m. They are relying on the tech who took blood (and said something about low blood pressure) to make sure the doctor (from lunchtime) knows about it.

Certainly, the vast majority of patient anxiety is swiftly diminished by the doctors and nurses devoted to that very purpose. Life threatening conditions are addressed (or ruled out) and the patient is assessed, stabilized, and safely moved towards the most appropriate destination. For both parties, the encounter ends with a favorable impression, even a positive memory. But some patients do slip through the cracks, and the entire process of care—from assessment through discharge and follow up—is vulnerable to missed opportunities.

While mismanagement of medical treatment is alleged in about one-quarter of ED cases,

Emergency Medicine’s greatest risk (and the focus of this Report) is diagnostic failures. Those cases most commonly stem from an inaccurate assessment performed by providers fording multiple streams of clinical information for several patients simultaneously. Analysis of such cases often highlights missed opportunities to order the appropriate diagnostic test—or to appreciate the test results and other potentially available information—leading to missed opportunities to initiate an appropriate consult or treatment. With only part of the full picture revealed, an acutely ill patient may be sent home, leaving a more threatening diagnosis looming just out of sight.

In almost half of cases arising in the ED, such errors lead to permanent injuries or death. Emergency Medicine physicians are the most frequently identified defendants in these cases (40 percent), but physician assistants and nurses are also vulnerable (with community hospital ED nurses named twice as often as their AMC peers).

ED patients feel extremely vulnerable. They are placing their trust—often their lives—in the hands of a team unfamiliar to them, and perhaps to each other.

general risks


statistics

The emergency department offers

equal opportunity access to those

in need of urgent—or not so urgent

care. According to the National

Hospital Ambulatory Medical Care

Survey, 123.8 million patients

(41 percent of the population) visited

US emergency departments in 2008

(last published report). Of these

visits, only 16 percent of patients

required immediate or emergent care.

Because their care is episodic and

fragmented, ED patients present

multiple care and management

challenges, especially in the

diagnostic process.

•According to the CRICO CBS

study, 3.8 of every 100,000 visits

result in a malpractice action

•30% of ED malpractice cases

involve a patient’s death

Diagnosis-related claims stem from errors throughout the process of care.

percent of cases*

average indemnity

1. patient notes problem and seeks care 6 % $ 529 K

2. history and physical exam 11% $ 816 K

3. ongoing monitoring of clinical status 30 % $ 653 K

4. ordering diagnostic tests 65 % $ 525 K

5. performance of diagnostic tests 5 % $ 670 K

6. interpretation of diagnostic tests 22 % $ 463 K

7. transmittal of test results to (ed) provider 7 % $ 576 K

8. consultation management 26 % $ 566 K

9. development of discharge plan 43 % $ 499 K 10. post-discharge follow up

(includes pending test results) 9 % $ 488 K

11. patient adherence with follow up 5 % $ 220 K*Cases may involve breakdowns at multiple points in the process.

70 % of cases cite emergency medicine as the primary responsible service

Other services frequently deemed responsible in ED-related cases:

academic medical centers

community hospitals

0% 5% 10% 15% 20% 25%

radiology

medicine

pediatrics

surgery

ob/gyn

psychiatry

percent of cases


Can your next patient give a complete, honest, and accurate history? Will you be able to access her medical records? Did you get a good handoff? Does anyone on your shift know her? Have any of those factors changed during the course of her visit?

Whether you serve a low-volume community hospital or a jam-packed urban teaching center, your population presents a broad diversity of complaints. You hope the patients, from Little Leaguers to octogenarians, can provide context of this visit and their medical history. Often, however, you will need more information from family, records, or colleagues in order to narrow—or broaden—your diagnostic focus.

If insufficiently integrated EMRs leave you prone to missing key clinical information, extra attention must then be paid to the symptoms your patient or her family members express the most concern about. This, of course, has to be balanced against

co-morbidities and any tendency to focus on a diagnosis you may have initially presumed.

Patients presenting with multiple traumas may draw multiple caregivers, but the poor historian with vague belly pain might demand equal vigilance. A patient with a significant medical history and affirming symptoms also poses the risk of a plausible answer that may limit your differential diagnosis, even when contrary clues are present.

Increasing volume amplifies the pressure as you and your ED colleagues contend with the slow simmer of patients’ discomfort, persistent distractions, and the queue in the waiting room. Amidst this everyday chaos lies the risk of critical patient information getting lost en route to those of you working to make management decisions and safe dispositions. Therein, potentially, is the difference between an expertly managed course in the ED or a slightly off-target trajectory ending in harm for patients whose condition changed over time.

About 85 percent of ED diagnosis-related malpractice claims cite an inadequate assessment.

triage and ongoing assessment


taking action

optimizing the triage Process:

standardized treatment Protocols

In 2010, to expedite throughput

in their increasingly busy ED, the

University of California San Diego

Medical Center (UCSD) implemented

standardized symptom-based

protocols. This enabled UCSD to

leverage the skills of their primary

nurses and begin treatment of

patients with specific symptomology

at the first point of assessment. With

standardized pathways, patients

with abdominal pain, respiratory

complaints, or psychiatric needs are

receiving more timely and efficient

treatment. Among the benefits are

shorter wait times and a significant

increase in patient satisfaction scores.

As volume continues to grow, EDs

that employ standardized treatment

protocols upon patient arrival can

further optimize nurses’ assessment

skills, and more effectively care for

patients across diverse needs. Acute

patients are efficiently triaged and

cared for in the appropriate setting,

while those with less pressing needs

can often be discharged from the

waiting room. Organizations that

have cultivated trust and teamwork

behaviors among providers will be

most successful in employing these

interventions.

Adult patients (18–64) constitute a disproportionate subset of diagnosis-related malpractice claims in the ED.

Providers acting without all available information increase the risk of a malpractice allegation.


community hospitals

percent of cases

failure to establish differential diagnosis 25 % 30 %

failure to note key clinical information 11 % 20 %

inadequate history and physical 7 % 12 %

case eX ample: assessment

A 49-year-old with a history of hypertension and cardiomyopathy presented to the ED with complaints of eye pain, blurred vision, and unsteady gait since the previous evening. After a limited physical exam, he was sent to the eye clinic for evaluation. Absent radiological studies or neurological consults, the patient was discharged with a diagnosis of corneal abrasion, macular elevation, and hypertension retinopathy. The following day, he returned to the ED with continued blurred vision and headache, and was noted to have altered mental status. CT scan revealed posterior and anterior artery stroke, leaving the patient with permanent visual impairment and cognitive deficits. (Case settled: $2.2M)

ed patients

ed claimants

0% 25% 50% 75% 100%

<18 18–44 45–64 >65 years old


In 39 percent of the ED diagnosis-related cases, a judgment error related to ordering a test or an image was noted. A mismanaged consult was a factor in 26 percent of cases.

TesTs

A typical ED malpractice case pivots on the clinicians missing a key opportunity to gather or share one more bit of knowledge. At these junctures, the practitioner must balance clinical judgment and production pressures. Relying too much on “seeing” a pattern before it is fully filled in, or allowing frustration with test/imaging access, turnaround times, and accuracy to hinder appropriate orders leaves you vulnerable to an incomplete problem list or a differential diagnosis not considered.

A standardized approach to diagnostic testing is often appropriate, but patients are safest when their ED team orders tests or images judiciously, rather than perfunctorily. This minimizes the risk of assumption and maximizes the value of results as an essential part of the diagnostic process. This also diminishes any tendency to treat counterintuitive results as anomalies.

CONsULTs

Claims that point to a mismanaged consult reflect numerous challenges in ascertaining expert input in the ED. In community hospitals, Emergency Medicine physicians often face a backed-up line for imagings and a prolonged wait for (sometimes reluctant) consultants to arrive. In academic facilities, residents serving as consultants present varying degrees of expertise; and curbside consults—although appealing in a crisis—can unsettle some of your colleagues.

In all settings are patients who bridge changing shifts. Maintaining breadth in the differential diagnosis, and continuity in the synthesis of data through those handoffs is paramount. EDs that structure team communication—and train their staff to use those structures—minimize the risk of losing valuable information, and decrease the propensity of diagnostic fixation and premature discharge.

tests and consults


taking action

the Role of Radiology

Citing CRICO’s CBS data, one

west coast AMC has instituted a

significant change for its Radiology

service. Armed with malpractice and

local data demonstrating the clinical

and financial risks associated with

delays that led to significant injuries

and deaths, leadership moved to

expand the hours when an attending

radiologist is available to provide

final reads for ED patients.

Radiologists providing critical

visuals and interpretations of your

ED patients’ complaints are also

susceptible to clinical judgment

errors or organizational systems

failures. This CRICO CBS study

found that, across all organizations,

Radiology was the responsible

service identified in seven percent of

the ED diagnosis-related cases, with

misinterpretation of tests being the

factor most commonly identified.

Organizations that ensure that an

attending radiologist has read a film

prior to transmission of findings to

the ED (or patient discharge)—and

those that leverage EMR technology

to ensure that physicians are reading

and responding to the most updated

radiological studies—are better

poised to draw accurate conclusions

and initiate appropriate treatment.

Failures or delays in ordering the appropriate tests or consults can interfere with your ability to arrive at an accurate diagnosis.

hospitals with... <25k ed visits/year

25–40k ed visits/year


>75k ed visits/year

percent of cases

failure/delay re: diagnostic test 52 % 57 % 51 % 60 %

failure/delay re: consult 48 % 34 % 35 % 37 %

case eX ample: tests and consults

Patient care may be jeopardized when trainees or nurses receive inadequate guidance from attending physicians.

11 % of diagnosis-related cases in academic medical center eds involve issues related to supervision of house staff or nurses.

A 53-year-old female presented to the ED at 5:30 a.m., complaining of sudden pain in her left axilla. Initial assessment revealed elevated blood pressure and heart rate, a low-grade temperature, and an elevated WBC (17,000) with left shift. No mass was palpable in the left axilla, her chest X-ray and CT scan were normal. After an undocumented (curbside) consult, the attending physician documented his decision not to start the patient on antibiotics. He diagnosed left arm strain and discharged the patient with pain medication. Her vital signs at discharge were not documented.

The patient returned to the ED the next morning complaining of severe pain, fever, chills, vomiting, and shortness of breath. She had a 103.3 fever, elevated heart and respiratory rates, decreased O2 sats, and her WBC was 14,000. Three hours later, the patient was noted to look “very ill.” She was started on antibiotics and an ultrasound revealed a small fluid collection in the left axilla.

A “stat” surgical consult was ordered, but two hours passed before the patient was seen by the consulting surgeon. She was admitted with a diagnosis of sepsis and possible left axilla abscess, with plans to rule out necrotizing fasciitis. She was taken to the OR for exploration of the left axilla mass, which revealed edematous, conglomerated lymph nodes, and venous thrombosis. Cultures confirmed Group A strep.

After an arrest and CPR in the OR, the patient was transferred to the ICU. She died the next day, following multi-organ failure, hypotension, and hypoxia. Her cause of death was streptococcal toxemia/toxic shock. (Case settled: $1.5M).


One out of every three ED malpractice cases has breakdowns in communication by the physicians, nurses, or both.

Physicians and nurses who excel at solving diagnostic problems via teamwork are drawn to Emergency Medicine where individuals working with limited information must rely on each other to divine the best strategy for each patient. Of course, these skills usually are practiced in an environment of steady distraction and disrupted communication. This is a chronic problem for the individuals putting the puzzle pieces together in a frenzied environment.

Getting the diagnosis right with minimal delay depends on effective team communication. If Dr. B doesn’t know what Nurse A knows, then Dr. B can’t complete the picture of patient C.

Every ED presents at least some of these significant challenges to ensuring that the entire care team has common knowledge:

• an EMR that reduces face-to-face interactions among the ED staff;

• a lack of touch-points for providers to synthesize independent bits of knowledge about a patient, especially at changes of shift;

• staff that over rely on each other’s habits and tendencies as substitution for asking and confirming; and

• a lack of sharing subtle changes in a patient’s condition that are noticed, but not noteworthy.

Peer-to-peer interactions, clinician-patient discussions, medical record documentation, etc., have to be clear enough to assist contemporary providers and comprehensive enough to guide subsequent caregivers. Organizations that offer training, practice, and support for teamwork skills that enhance clinical decision-making can minimize the risk of uncoordinated care. Continuous collaboration between physician and nurse leadership that involves frontline workers from all disciplines is likely to be effective in driving sustained safety improvements.

synthesis and diagnostic decision-making


Data Mining

Leveraging technology

to Enhance Patient care

Electronic medical records in the ED

present opportunities to leverage

data mining technology to support

accurate patient assessment and

treatment decisions. The Queriable

Patient Inference Dossier (QPID)

is one such tool. Developed at

Massachusetts General Hospital,

QPID supports Emergency Medicine

providers’ ability to rapidly search

a patient’s medical record for

salient past medical history, better

informing their assessment and

treatment plan. Such information

assists providers in obtaining results

of pertinent tests and imaging,

reducing the need for additional

imaging studies and alerting

providers to contraindications for

testing and treatment that their

patient may not be able to readily

share from memory.

How well are you communicating critical information regarding your patient’s condition?

hospitals with... <25k ed visits/year



>75k ed visits/year

percent of cases

communication failures among providers

26 % 17 % 24 % 23 %

case eX ample: decision-making

A 47-year-old male with history of asthma presented to the ED complaining of shortness of breath and chest tightness since the prior day. The initial nursing documentation reports SOB episodes consistent with asthma symptoms and a pulling pain in the chest with deep breaths. They also referenced a recent history of a pulled calf muscle one week prior, with bruising and swelling, and a positive Homan’s sign. The attending physician noted the patient was alert, fully oriented, and in no acute distress. The patient also reported recent exposure to new cleaning products at work.

Without scrolling further down in the electronic medical record to view the nurse’s note, the physician ordered no further studies, diagnosed the patient with asthma exacerbation, and discharged him with instructions to use his inhaler at home. The following day, the patient was found dead at home, secondary to massive bilateral pulmonary embolism. (Case settled: $315K).

Are you appropriately staffed?

22 %of ed cases involve issues related to staffing over the weekend, night shift, or a holiday.

Clinical judgment errors at the point of diagnostic decision-making put providers and patients in jeopardy.


community hospitals

percent of cases

misinterpretation of a diagnostic study 23 % 17 %


discharge from the ed

Allegations of premature discharge are common among patients involved in malpractice cases. Will you be surprised if the patient you just discharged returns tomorrow?

In a service area where diagnostic ambiguity is more the rule than the exception, the physicians and nurses discharging patients rarely hear the end of the patient’s story. For Emergency Medicine physicians, the inevitable sending of a patient home, to an inpatient service, or to a PCP, generally limits meaningful feedback about the accuracy of their diagnosis and treatment plan. Are you concerned about any of these potential risks in your ED:

• test results received in the ED post-discharge;

• incomplete or unspecific discharge or follow-up instructions;

• patient’s (or family’s) incomplete comprehension of instructions;

• patient’s PCP unaware of ED visit and/or need for follow up;

• discharge accelerated due to ED production pressure;

• discharge without reconciliation of concerning symptoms or test results; or

• patient abandoned between ED discharge and inpatient admission (i.e., boarders).

Without formal and consistent direct feedback, ED physicians have to contend with a certain amount of anxiety about these and other post-encounter risks—and where to focus patient safety attention and resources.

Systematic input from the patient population, the primary care community, and hospital-based departments can provide ED leaders with a real-time understanding of strengths and weaknesses in the ED’s discharge process. Combining that insight with aggregated, comparative analysis of deeply coded malpractice claims from CBS opens a window into your most critical vulnerabilities.


taking action

Handoffs and transitions: Facilitating

communication among Providers

In an effort to facilitate ownership

and accountability for patients

assumed by an oncoming ED

shift, one AMC in the Northeast

developed triggers for reassessment

of boarding patients. These include

time frames, e.g., visits longer than

six hours, patients with altered

mentation at time of sign out, or any

concern raised by any member of

the care team.

Although issues directly related to

boarding are not common in ED

malpractice cases, these patients

raise justifiable concern and can

drain resources away from patients

with more acute needs. And, when

an extended observation or boarding

patient’s visit spans shift changes

(sometimes multiple days), providers

risk losing critical information at

handoffs or fail to assume full

accountability. Organizations that

have been able to mitigate these

risks employ communication

protocols such as standardized

transitions, coordinated nurse-

physician sign outs, and second

opinions at handoffs.

41 % of diagnosis-related ed cases involve inadequate assessment leading to premature discharge.

case eX ample: discharge

A 30-year-old female presented to the ED with history of severe, bilateral lower abdominal pain with nausea and vomiting over the previous three days. Medical record documentation revealed a limited abdominal exam with findings of possible supra pubic pain and no abdominal tenderness. There was no documentation of any abdominal rebounding, or tenderness to the kidney area. No gynecological exam was performed. Labs, urinalysis, and blood cultures revealed possible UTI: white and red blood cells in the urine and elevated white blood cell count with left shift (but specimen contamination was suspected). An abdominal X-ray was negative. The patient was diagnosed with a UTI, prescribed antibiotics, and discharged—despite a 102.3 temperature and no resolution of her abdominal pain or a Urology consult for possible kidney infection.

Two days later, urine cultures returned “no growth,” confirming specimen contamination, and invalidating the diagnosis of a UTI. That same day, the patient was admitted with a ruptured appendix. (Case settled: $50K)

Top Final Diagnoses in ED Casespercent of cases

average indemnity

orthopedic injuries 14 % $ 150 K

stroke 9 % $ 550 K

aneurysm, embolism, thrombosis 8 % $ 500 K

myocardial infarction 7 % $ 600 K

infection, blood 7 % $ 910 K

Premature discharge is often preceded by cascading issues and missed opportunities that span the ED visit.


If the ED encounter that led to an allegation of malpractice was their only interaction, then ED physicians may be hard-pressed to recall the patient, or the circumstances that triggered that action.

case dispositions

The absence of an established physician-patient relationship may make it easier for ED patients (or their families) to challenge the quality of care provided than in care encounters between familiar parties. On the other hand, the urgency of the situation and the appreciation for the diagnostic challenges ED clinicians face may curtail a patient’s need to assign blame. Malpractice insurers, defense attorneys and, in some cases, jurors, are tasked to measure the patient’s expectation against the standard of care in the ED—where the components for clinical decision-making differ from other care settings.

The disposition of Emergency Medicine cases—especially those alleging a diagnostic

error—demonstrates commonality with other high-risk areas, such as obstetrics and surgery. And across all clinical services and disciplines, better communication (with colleagues and with patients) is key to fewer errors that lead to patient harm. Likewise, across all clinical services and disciplines, better communication after an adverse event benefits both patients and providers. CRICO Strategies encourages organizations of all stripes to find opportunities to improve interdisciplinary teamwork—via drills, role playing, simulation, etc. We also promote programs that encourage disclosure and apology (when appropriate) and those that support clinicians who have been involved in a tragic adverse event (always appropriate).


DEPosition RounDtabLE

Preparing Providers for

Difficult conversations

The factors contributing to lawsuits

vary by shades and degrees; the

stress and discomfort endured

by physician defendants does

not. Being deposed requires the

physician to recall latent facts of their

clinical impression and reasoning

under the emotional—even

physical—stress of responding to an

adversarial attorney across the table.

Recognizing the need to support

their providers in these trying

situations, the University of Florida

(UF) convened a CME-accredited

Deposition Roundtable for their

Emergency Medicine faculty and

residents. Moderated by UF’s self-

insurance program, trial attorneys

and a clinical psychologist focused

on methods for helping malpractice

defendants navigate key trouble

spots: responding to hypothetical

and other challenging questions,

addressing documentation gaps and

omissions, and answering within

one’s scope of expertise.

Conversations surrounding legal

proceedings are among the

most significant and challenging

conversations a provider will have

in their professional careers.

Offering support is critical to

ensuring that physicians and

nurses are able to continue

providing excellent patient care.

For 647 diagnosis-related ED malpractice cases closed from 2006–2010

33 % closed with a payment

508,000 ≥ $ 1MIL.

average cost of cases closed with payment = $

4% of cases closed with a payment

Physicians account for the vast majority of individuals named in ED malpractice cases.


community hospitals

defendant percent of cases

organization 50 % 67 %

staff physician 28 % 19 %

resident/fellow 13 % 0 %

nurse 5 % 11 %

physician assistant 1 % 2 %

other 3 % 1 %


model initiatives in ed patient safety

tRansFoRMing tHREE vuLnERabLE EDs

Six years ago, the three emergency departments run

by the Cambridge Health Alliance (CHA) suffered from

significant throughput challenges, low satisfaction scores,

and safety vulnerabilities. Recognizing the potential

benefits of some simple, low cost changes, CHA’s Chief

of Emergency Medicine rapidly transformed those three

vulnerable EDs into some of the highest performing

departments in the country. Critical to their success was

teamwork. This was supported by a commitment by all

staff to provide the best care possible while maintaining

optimal patient flow—paired with a leadership promise

of 24/7 accessibility for managing any situation that

interfered with these goals. From there, key operational

enhancements were made:

• in-room registration and rapid assessment;

•reengineered workflow with ancillary services to ensure

efficient, coordinated throughput and appropriate

turnaround times;

•standardization of policies, protocols, and patient

care areas across all three sites to support efficient

performance regardless of location;

•admission to any inpatient bed from any ED across the

three hospitals; and

•a rapid escalation process implemented to empower

providers to maintain admission flow.

Despite a 25 percent growth in volume since 2006, 97

percent of ED patients are seen within five minutes of

arrival and compliance with quality metrics is at or above

the 95th percentile. With such remarkable changes in

CHA’s safety culture, positive signs in their malpractice

profile are surely soon to follow.

HuMan FactoRs EnginEERing

In 2010, as another step in its comprehensive approach

targeting the fundamental drivers of their patient safety

risks, MedStar Health founded the National Center for

Human Factors Engineering in Healthcare. MedStar’s

goal is to reduce medical errors by improving working

conditions (and increasing efficiency and satisfaction)

through the application of human factors engineering

science. Current Emergency Medicine-related projects

include:

•understanding the best practice design characteristics

of ED imaging systems and developing a prototype

dashboard to integrate multiple ED imaging systems;

•understanding the tasks and activities of caregivers

using manual ED status boards (i.e., white boards) to

design and evaluate prototypes of electronic ED health

IT systems;

•discovering the barriers to timely disposition of patients

from the ED, and then identifying how the process could

be better facilitated;

•studying team performance in emergency trauma

resuscitations, focusing on identifying team leadership

behaviors which enhance the performance of the

team; and

•developing a hazard alert loop system for formal,

live capture of ED safety hazards, a strategy that has

resulted in dramatic increases in physician reporting.

the following initiatives exemplify ongoing attention to the risks to which Emergency Medicine providers and patients are

exposed. Working together, either as an institutional team or as part of a multi-institutional collaborative, is the consistent

theme across these success stories.


EMERgEncy MEDicinE LEaDERsHiP counciL

Recently, Emergency Medicine leaders from 19

organizations convened by CRICO and CRICO Strategies

addressed missed and delayed diagnosis malpractice

claims. Employing CBS data and their own experience, the

Emergency Medicine Leadership Council (EMLC) identified

underlying factors at the root of ED cases.

The most prominent factor identified was a gap in patient

information communicated between the MDs and RNs.

With consensus that optimal communication at critical

junctures is key to reducing diagnosis-related errors, the

EMLC field-tested improvement strategies. Those, in turn,

led to defining a set of best practices for optimizing ED

physician-nurse communication including:

•structured communication at critical points during the

ED visit: e.g., triggers, huddles, discharge time-outs; and

•ongoing education: e.g., teamwork training, simulation,

and professional development.

LEaRning FRoM EXPERiEncE

After the Emergency Medicine chief at Maine Medical

Center recognized the value of capturing the breadth

of safety-related intelligence available, he seized an

opportunity to formally share that information with a

highly engaged multidisciplinary staff interested in making

improvements. This was the genesis of Maine Medical’s

Multidisciplinary Case Review Team, a monthly physician-

led forum to discuss recent events involving suboptimal

care. Action steps are identified and key vulnerabilities are

captured in a searchable database to prioritize themes

for improvement. Enthusiastic participation by multiple

disciplines—and staff spanning multiple roles—has

made the review team an effective force in patient safety

improvement efforts.

“We are seeing the ED culture transformed before our eyes.”

—Doug salvador, associate chief Medical officer, Maine Medical center


siMuLation-basED ED tEaM tRaining

After CRICO and CRICO Strategies convened

Emergency Medicine leaders to address key risks in

the ED, they determined that information gaps and lack

of communication among providers played a key role

in their malpractice cases. With a focus on optimizing

communication between physicians and nurses, the

ED collaborative recommended a curriculum based

on actual malpractice case scenarios. In response,

CRICO developed—and gained board funding for—a

high-fidelity simulation training program to enhance

communication skills and team behaviors within its

insured organizations EDs.

Using multiple scenarios that simulate an active ED

setting, including an unstable patient at triage, a patient

with deterioration in the ED, patients with abnormalities

not addressed at discharge, and patient handoffs, the

curriculum is designed to improve providers’ ability to:

•recognize barriers to gathering and integrating

complete information;

•use a designated method (e.g., SBAR, IPASS) for

receiving and transferring complete information; and

•lower the barriers for speaking up, by consistent

use of agreed upon communication prompts, (e.g.,

triggers to identify and respond to unstable patients,

physician-nurse huddles, and discharge timeouts with

reconciliation of abnormal vital signs).

By the end of 2012, the Emergency Medicine Team

Communication Training Program will have reached

more than 1,500 ED personnel across the CRICO

system, providing tools and enhancing skills to improve

the communications that are critical to keeping ED

patients safe.


comparative benchmarking system (cbs)a landscape view of key clinical risk areas

Overviewmonitoring high-level trends in claims experience through cbs allows strategies and its cbs partners across the country to keep abreast of emerging vulnerabilities affecting high-risk service areas, and to share model interventions.

top aLLegatIons

surgical treatment

medical treatment

diagnosis-related

0% 10% 20% 30%

percent of cases

percent of total incurred dollars

top ResponsIbLe seRvIces

surgery

medicine

nursing

ob/gyn

0% 10% 20% 30%

percent of cases


aLLegatIon tRenDs

30%

20%

10%

2006 2007 2008 2009 2010

pe

rc

en

t o

f c

as

es

diagnosis-related

medical treatment

obstetrics-related

surgery-related

Containing more than 200,000 medical malpractice

claims and allowing for aggregated analysis and

peer comparisons, CRICO Strategies’ Comparative

Benchmarking System (CBS) provides its users the

credibility of analyzable malpractice data. Broad,

comparative analysis of otherwise rare events allows

patient safety leaders to identify reliable themes that unite

seemingly unique clinical encounters. This comparative

perspective sharpens the focus on an organization’s

otherwise undifferentiated experience, and arms patient

safety leaders, clinicians, and executives with the data

necessary to make proactive changes to protect their

patients and providers from significant harm.

Based on comprehensive review of both medical records

and claim files, our expert clinicians apply CRICO’s unique

coding taxonomy to each claim and suit within the CBS

database. Capturing human and cognitive factors, system

issues, and both the clinician and patient perspective,

our proprietary coding taxonomy allows insight into

the factors driving an organization’s most pressing

vulnerabilities. Using malpractice data as a “divining rod”

will sharpen resource-stressed leaders’ focus on the

clinical and/or systemic drivers of their most compelling

risks. Benchmarking with comparable peer organizations

across the country provides visibility into areas of

particularly high risk for clinical error and financial loss,

and establishes a powerful platform for development of

targeted interventions to protect patients and providers.


comparative benchmarking system (cbs) a landscape view of key clinical risk areas

Surgery

top contRIbUtIng FactoRs*

percent of cases

technical skillintraoperative complications 34 %

clinical judgmentinappropriate selection of procedure or surgical approach 18 %

clinical judgmentfailure/delay in ordering a diagnostic test 13 %

communicationamong providers regarding patient’s condition 9 %

clinical judgmentfailure to respond to repeated complaints of symptoms 9 %

organizations that systematically evaluate the human and environmental factors driving technical errors in each clinical specialty are best positioned to develop successful, targeted, interventions.


orthopedics

general surgery

neurosurgery

0% 10% 20% 30%

percent of cases


InpatIent sURgeRy case Rate

12

9

6

3

2006 2007 2008 2009 2010

ca

se

s p

er

10

k s

ur

ge

rie

s


community hospital

*cases generally have 2–3 factors identified.

Outpatient Diagnosis-related Claimsproviders delivering long-term, episodic care are vulnerable to diagnostic errors arising from flawed clinical judgment and communication lapses. systems for closed-loop clinical management and education on the risks of diagnostic error are critical for supporting safe, office-based care.


medicine

radiology

surgery

0% 20% 40% 60%

oUtpatIent DIagnostIc pRocess oF caRe*

percent of cases


top canceRs

number of cases asserted 05–07

number of cases asserted 08–10

breast

colorectal

lung

prostate

0 25 50 75

percent of cases total incurred

patient notes problem and seeks care 2 % $ 9 Mhistory/physical and evaluation of symptoms 36 % $ 164 Morder of diagnostic/ lab tests 59 % $ 275 M

performance of tests 3 % $ 10 Minterpretation of tests 42 % $ 175 Mreceipt/transmittal of test results 11 % $ 46 Mphysician follow-up with patient 16 % $ 79 M

referral management 32 % $ 105 Mpatient compliance with follow-up plan 11 % $ 27 M

*cases may involve breakdowns at multiple points in the process.


Medicationorganizations leveraging electronic medical records and patient portals are best poised to monitor and communicate with patients to ensure safe and effective management of high-risk medications.

top ResponsIbLe seRvIces anD top DRUgs

meDIcatIon pRocess oF caRe

outpatient inpatient

percent of cases

ordering 18 % 21 %

pharmacy dispensing 4 % 4 %

provider administration 12 % 22 %

monitoring & management 50 % 36 %

other 17 % 17 %

oUtpatIent/InpatIent tRenD

75%

50%

25%

2006 2007 2008 2009 2010

pe

rc

en

t o

f c

as

es

outpatient

inpatient

cases total incurred

coumadin 27 $ 8 M

dilaudid 20 $ 9 M

heparin 18 $ 6 Mcontrast media 15 $ 6 M

fentanyl 12 $12 M

pe

rc

en

t o

f c

as

es

100%

75%

50%

25%

medicine

nursing

surgery

emergency

other

9

6

3

2006 2007 2008 2009 2010

top aLLegatIons

ca

se

s p

er

10

k b

irt

hs

case Rate

Obstetrics


community hospital

top contRIbUtIng FactoRs*

percent of cases

substandard clinical judgment 70 %

technical error 32 %

miscommunication 31 %

inadequate documentation 23 %

administrative failures 21 %

ineffective supervision 13 %

delay re: fetal distress

performance of vaginal delivery

management of pregnancy

0% 10% 20% 30%

hospitals with <2k births per year

hospitals with >2k births per year

*cases generally have 2–3 factors identified.

delivering safe obstetrical care requires impeccable clinical interpretation skills, effective interdisciplinary communication, and decisive actions by cohesive teams. organizations that employ multidisciplinary simulation-based team training, and provide regular opportunities for practice are less vulnerable to patient harm.

CRICO sTRaTegIes

Since 1976, CRICO has been the medical malpractice company owned by

and serving the Harvard medical community. Our success is rooted in a data-

driven approach to claims management and patient safety, and is the outcome

of years of service to our members.

The establishment of Strategies in 1998 allowed CRICO to reach beyond

Harvard to create an international membership of physicians, health care

systems, and their medical malpractice insurers, using our proven

methodologies: comparing analyses of claims data, sharing effective patient

safety practices, and promoting dialogue among a community of peers.

For more information about the CBS database and Strategies services

and products, contact: Gretchen Ruoff, mph, cphrm, 617.679.1299,

or [email protected].

©2012 CRICO

Editor: Gretchen Ruoff, MPH, CPHRM Content: Jock Hoffman and Winnie Yu Photography: Richard SchultzProduction: Alison Anderson

101 Main Street • Cambridge, MA 02142t 617.495.5100 f 617.495.9711www.rmfstrategies.com

Is your biggest concern the ED, the OR, Labor & Delivery… or the doctor’s office?CRICO Strategies can help you identify where to focus your patient safety resources. Our Comparative Benchmarking System and other risk intelligence tools accelerate your ability to uncover and address your organization’s key patient safety vulnerabilities.

Access our Benchmarking Reports on Surgery and Obstetrics risks at rmfstrategies.com.

We look forward to working with you to improve the safety of care delivered in your organization, sharing comparative intelligence, analytical insight, and proven solutions. For more information about how we can help you reduce the risk of patient harm, please visit our website www.rmfstrategies.com, or call us at 617.679.1299.

—Jeff Driver

Stanford University Medical Indemnity Trust

—Darrell Ranum

The Doctors Company

It’s the leverage that gets the ball rolling. When I take data to physicians, there’s a credibility we’ve never had before. The data are so much more valuable than opinions.

Dollar-for-dollar, the CRICO Strategies-Stanford data partnership proves among the highest returns for Stanford’s risk management investments.

Would your patients benefit from more effectively functioning teams?Learn more about CRICO Strategies’ team training programs to improve the care in your Emergency Department, Labor and Delivery Unit, Operating Room, or other clinical care environments.

—Joel yohai, mD

Chief Medical Officer, Catholic Health System of Long Island

I believe in CRICO’s team training program. I think that teamwork is essential to providing care in this very complicated world of medicine.

—ann shea-Lewis, mba, Rn

Director of Maternal-Child Health, St. Charles Hospital

Through staff education, interdisciplinary cooperation, and ongoing mentoring, the CRICO team training program has had a profound impact on patient care.

Documents

2011 Annual Benchmarking Report - CRICO/media/Files/_Global/KC/PDFs/crico... · crico Strategies is pleased to present Malpractice Risks in Emergency Medicine, our third Annual Benchmarking