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Closed claim study can show what's really wrong
Failure to communicate is the underlying cause of many malpractice claims, according to a recent closed claim study by the American College of Surgeons (ACS) in Chicago. Risk managers can conduct a similar closed claim study that will reveal useful information specific to what is happening in your own organization, rather than depending on more general reports.
The ASC Closed Claim Study was conducted under the guidance of the group's Patient Safety and Liability Committee, reviewing 460 liability claims that occurred between April 2004 and February 2006. When the root causes were analyzed, the most common problem involved communication, says F. Dean Griffen, MD, FACS, a surgeon in Shreveport, LA, and the immediate past chair of the American College of Surgeons Patient Safety and Liability Committee. (See box below for more on the findings of the ACS study.)
Doctors often need to ask for more info
When it comes to failure to communicate, a common example is the physician who relies only on the information offered about a patient's condition without asking for more details, according to the American College of Surgeons (ACS) Closed Claim Study, which involved a review of 460 liability claims that occurred between April 2004 and February 2006.
Problems stemming from failures in communication occurred mostly with patients and families (36 claims), physicians (35 claims), followed by nurses (19 claims), laboratory personnel (one claim). Griffen says the communication failures included failure to listen or solicit information (47 claims) and the failure to convey information (46 claims). With listening problems, the study determined that defendant surgeons heard selectively and weighted input in favor of the best scenario, which led to failure to act and errors of omission.
In some cases, surgeons failed to solicit more information than what was volunteered by others with less experience and insight, content to hope that all was well instead of probing for more information that might require action. For instance, in one case a resident called the attending physician during the night and reported admitting a patient with abdominal pain. The resident said he thought the patient was constipated. Admitting a patient with constipation to a surgery service is unusual and typically requires an explanation, but the attending physician did not ask for more information. The patient died that night, and an autopsy revealed a ruptured aneurysm. Records revealed that the patient was anemic and hypotensive in the emergency department before admission.
The reviewers found that communication problems resulted from the failure to diligently spend enough time to accomplish ordinary tasks rather than the failure to possess skill and brilliance to accomplish extraordinary feats. "No tort law holds us as surgeons to a standard of perfection where technical skills are concerned. To err is human," they said. "But failures in the area of professional behavior are inexcusable, and diligently spending the required time certainly falls into that rubric."
The full ACS report is available online at www.facs.org/fellows_info/bulletin/2007/griffen0107.pdf.
"Most of our liability and unsafe care occurs in the preoperative and postoperative periods, not necessarily because of anything that happens in the operating room," Griffen tells Healthcare Risk Management. "One surprise was that, so often the problems that create adverse outcomes and liability relate to a failure to do ordinary things — the things that anybody can do if you just take the time and use due diligence, including adequate communication."
Need more talk with patients, families
Communication issues are not restricted only to staff and physicians, Griffen notes. The study also suggests that health care providers need to communicate more clearly and more openly with patients and family members.
"When we communicate better with patients and family, they understand our problems better and their expectations can be properly balanced," he says. "For instance, if a paraplegic patient is not cooperative, they are at very high risk for bed sores no matter what we do. So if the patient's family is told everything that you are trying to do and how the patient's actions affect that, the family will be more understanding when the inevitable bed sores occur."
Similarly, Griffen advises physicians to be up front with patients who pose a special challenge. Rather than professing limitless confidence and optimism, it can be better to communicate the difficulty posed by a patient's surgery, he says. Improved communication can manage the patient's expectations.
"I compare it to a golfer in the rough, with the ball behind a tree," he says. "If you're an obese patient with multiple health problems and I have to operate on you, I'm starting out at a disadvantage. The patient should know that in that situation, even the best golfer in the world is going to have a hard time hitting it right to the green."
Griffen's research found that failure to communicate with patients and families produced nonmeritorious claims. "When we health care professionals didn't communicate with each other, it produced meritorious claims," he says.
While broad studies such as the ACS work can be useful, Griffen notes that a closed claim study of a particular organization can be helpful in providing more specific data. The study should be focused on improving patient safety, and the reduction in claims will be a secondary gain, Griffen says. The benefit of such a study is that it can reveal problems previously known or underestimated, he says.
A closed claim review, when executed well, will help you identify and find solutions to your own problems, says Cynthia Marcotte Stamer, JD, an attorney with the law firm of Glast Phillips in Dallas and a national risk management adviser to health care providers. That can be more useful than focusing your risk management efforts on general "big picture" issues that apply to everyone across the board, she says.
A closed claim review also can help you focus your limited resources on the issues that matter most to you, she says. The result might be a concentrated focus on an issue that can make a big difference for your organization, rather than a scattershot approach to a lot of general issues.
Use all the tools you have to probe as deeply as you can, but do it with some foresight into what you're going to do with the information you put together, Stamer says. "That means you need to put some thought into what is protected information and what you will do with the data once you're finished," she says. You don't want to simply collect information about your failings, do nothing with it, and put it on a shelf, Stamer says. "That's just an academic exercise, not good risk management," she says.
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