One-quarter of all malpractice claims in a recent closed claim study involved surgical allegations, second only to diagnosis-related allegations. The authors of the study said standardization and practice contribute to successful outcomes. Routine and rigor also are vitally important.
Coverys, a malpractice insurer based in Morristown, NJ, conducted a study of five years of closed malpractice claims data from 2014 through 2018. The researchers were surprised that performance and technical skills remain the largest risks in surgery, says Sharon Gilmore, MHA, BSN, RN, CPHRM, CPHQ, senior risk specialist in the risk management department at Coverys.
“For technical risks, we’re thinking that homing in a little bit more on credentialing and privileging would help, to be sure that the surgeon has performed those types of surgeries before and has done so successfully,” she says. “We’re also thinking of the impact from surgeons being pressured to do more with less time, being encouraged to move more patients through the OR in less time and with fewer resources.”
The study authors also determined that 78% of surgical allegations were related to practitioner performance during surgery. Forty-seven percent of claims from more than 50 surgical specialties involve three specialties: general surgery (22%), orthopedic surgery (17%), and neurosurgery (8%).
Distractions in the OR
Gilmore says the research indicates specific process vulnerabilities at each stage in the surgical episode of care and unique challenges related to the top three specialties. Risk managers can help surgeons understand those issues and improve outcomes, she suggests. (The report is available online at: https://www.coverys.com/knowledge-center/a-dose-of-insight-surgery-risks.)
“Distractions are always a major concern. As we do on-site visits, we often see high traffic in and out as they’re bringing in equipment, possibly because the OR was not prepared appropriately beforehand,” Gilmore says. “Conversations also can be a distraction, as they are talking about their weekend or what’s happening on the floor. Cellphones can be a problem, and we see that especially in anesthesia providers because there are long periods while they are monitoring the patient and may spend that time on their phone instead of aggressively monitoring the patient.”
Coverys recommends limiting cellphones in the OR. Gilmore knows of one hospital that requires all clinicians to drop their phones in a collection basket before entering the OR.
For technical performance concerns, Gilmore recommends strong peer review and performance evaluations of surgeons and their teams.
“We need to identify if there are any lapses in technical knowledge or performance, and that is not necessarily going to come from the standard review process when a surgeon is credentialed. If you think there is any reason to doubt proficiency, there should be a focused effort to evaluate more thoroughly and more frequently,” Gilmore says. “Ongoing reviews can reveal a lot of opportunities for improvement.”
Standardization is important in improving surgical outcomes, Gilmore says. Not only should the surgical team be following best practices, but standardization helps highlight any deviations that can affect outcomes, she says. Gilmore recalls working with a surgeon whose motto was “Same way every day, team. Let’s go.”
“Patient selection is another big issue. The patient may want to use this provider and the surgeon may want to do the procedure, but does the hospital have the resources? Does the provider have the skill level to serve this particular patient well?” Gilmore says. “No two patients are the same. We have to consider the challenge afforded by this patient, this procedure, this facility, and this surgical team. If they are not a match we are setting ourselves up for failure.”
Patient handoffs and communication also are key to reducing surgical liability, Gilmore notes.
The data presented in the closed claim study present an opportunity for risk managers to assess their own programs. “A lot of people know that these issues are hot spots, but they lose focus over time when they get into the daily routine of providing surgery,” Gilmore says. “The data in the report can be used as a way to look at how your own facility is doing in these areas and to get surgical teams focused on these key areas that have a real impact on quality improvement.”
- Sharon Gilmore, MHA, BSN, RN, CPHRM, CPHQ, Senior Risk Specialist, Risk Management, Coverys, Boston. Phone: (800) 225-6168.