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At the UMass Memorial Medical Center ED in Worcester, analyzing medical malpractice data has become a powerful patient safety tool.1
“We periodically look at a variety of reports that identify what we are seeing relative to cases arising out of the ED,” says Timothy Slowick, director of claims management for UMass Memorial Health Care, the parent company of the Worcester facility. This includes adverse event data, root cause analysis, reportable events, and malpractice claims data.
The ED can compare itself to peers in the academic medical center world in terms of malpractice, and learn whether the ED is an outlier, better-performing, or if specific areas are problematic. Once all the data are considered, says Slowick, “we develop a plan of action to move forward from there.” These are some of the changes that were made in the UMass Memorial Medical Center ED:
• Ultrasound coverage is now 24/7. The ED handled four malpractice cases that alleged failure to recognize, evaluate, or treat testicular torsion. All involved teenagers who had lost a functioning testicle from torsion. Three of four cases involved patients who came to the ED at a time of day when ultrasound was not immediately available, which delayed diagnosis and treatment.
An analysis (using data from the Controlled Risk Insurance Company [CRICO] Strategies’ National Comparative Benchmarking System database of malpractice claims) showed that UMass Memorial was an outlier compared to its peers.
Based on the malpractice lawsuits, and a series of root cause analyses, it was determined the ED did not have enough ultrasound coverage ensure these patients were a high priority and seen and screened quickly. “We used our claims data and the significance of the injury to do a risk/benefit analysis to push for 24/7 coverage of ultrasound for that particular population,” says Janell Forget, RN, BSN, JD, senior director of risk management for UMass Memorial Health Care. The ED now provides full-time, in-house ultrasound services to address torsion and other emergencies.
• Several claims involved incidental findings on ED patients who were not followed up on. The findings were either not properly flagged, or were not properly sent for follow-up. An ED follow-up nurse was responsible for test results, such as blood cultures, that come back after patients leave the ED. “We added the follow-up of incidental findings in the ED into that person’s workflow,” Forget says.
The nurse now sends electronic notifications in real time to primary care physicians, even if they are not within the health system. “But there is still a human who does the follow-up and makes sure the results get to where they need to be,” Forget adds. If the patient is homeless and cannot receive the results through traditional methods, it is the follow-up nurse’s responsibility to make sure the patient is notified or brought back in.
• Airway management training is provided to ED providers. The training covers practical skills training for intubation and surgical airways. Initially, the code airway curriculum was focused primarily on the OR and anesthesia providers. “This past year, it was extended to the ED,” Forget reports.
Data were used to justify the health system’s multimillion-dollar investments in ultrasound coverage and airway management training, and the process continues. Recently, risk management performed a 10-year look back on all its data to decide on a focus for 2020. “Not surprisingly, it’s diagnosis-related,” Forget says. “We found that 75% of our diagnosis-related cases come out of the ED and the ambulatory areas.”
The claims department delineates issues that really need significant intervention, and issues that need more minor interventions. Organizations sometimes take a “wait and see” approach with malpractice risks. “For the one case that you get a year, it could be that no one pursues litigation, or it could be a $5 million hit. It’s a gamble,” Forget says.
Remaining transparent with malpractice claims data helps all stakeholders be proactive. “We feel so strongly about getting the information out that our chair of emergency medicine is a member of our claims committee and self-insurance program committee,” Slowick reports. ED clinicians learn the ultimate outcome of malpractice lawsuits, both for the patients and the financial payout. “Some of the data I produce is older, three to five years, by the time it becomes actionable,” Slowick says.
ED providers may fail to see the urgency, or assume they have addressed it already. To show the issue is current, claims managers incorporate event reporting data with malpractice data. “We can say, ‘Not only did this happen in 2017, but it also happened yesterday,’” Slowick explains.
Risk managers go to the ED unannounced routinely. “We look at corrective actions that are not so grandiose, in-the-moment, small things happening, for continuous improvement,” Forget says. Two recent examples:
“There is a close relationship between the claims people who handle ED cases, risk managers who manage the ED cases, and ED clinicians,” Slowick says. This makes it more likely clinicians will share information on what is going wrong in the ED. Risk managers carry responsibilities specific to departments. “You are able to do better risk mitigation when you have alignments like that,” Forget says. For smaller hospitals that cannot assign a dedicated risk manager to the ED, an alternative is to put a leader trained in risk management within the ED.
“If you don’t have that relationship, you have no idea what’s going on,” Forget says. “You can’t really do proactive mitigation. You are always behind the eight ball — and sometimes really far behind.”
By spending time in the ED, risk managers hear about problems right as they are happening. “There are things we do on a daily basis, based on interactions with the ED, to minimize near misses and the likelihood of their becoming a huge situation,” Forget says.
ED providers air concerns about boarding of admitted patients, such as pressure ulcers for patients who are held for long periods. Risk managers then share the concern with hospital administrators. “We hear about serious quality events that may not end up as formal claims,” Forget says.
Risk managers and claims managers encourage ED providers to reach out. “Staff must be willing to put it all out there, air their dirty laundry, and freely converse with the people who can help them,” Forget says.
Financial Disclosure: The following individuals disclose that they have no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study: Arthur R. Derse, MD, JD, FACEP (Physician Editor), Michelle Myers Glower, MSN, BSN, RN, NEA-BC, CNEcl (Nurse Planner), Stacey Kusterbeck (Author), Jonathan Springston (Editor), Jill Drachenberg (Editor), Leslie Coplin (Editorial Group Manager), and Amy M. Johnson, MSN, RN, CPN (Accreditations Manager).