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A PROPOSAL FOR ADDRESSING THE EFFECTS OF HINDSIGHT AND POSITIVE OUTCOME BIASES IN MEDICAL MALPRACTICE CASES
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EVIDENCE-BASED MEDICINE
A MANEUVER FOR SHOULDER DYSTOCIA
BASIC ERRORS BY DOCS CAUSE OF MOST MALPRACTICE
From The Associated Press
Basic errors made by doctors, including tests ordered too late or not at all and failure to create follow-up plans, played a role in nearly 60 percent of cases in which patients were allegedly hurt by missed or delayed diagnoses, a recent study found.
Researchers in the study, published in the Annals of Internal Medicine reviewed 307 closed medical malpractice claims, 181 of which allegedly involved diagnostic errors that ended up harming patients. A large majority of those cases involved various types of cancer.
While researchers acknowledged that most claims involved several factors, they said major ones included mistakes by doctors: failure to order appropriate diagnostic tests (100 cases); failure to create a proper follow-up plan (81); failure to obtain an adequate history or perform an adequate physical examination (76); and incorrect interpretation of tests (67).
Doctors not involved with the study said the findings highlight the fact that physicians and patients need to err on the side of caution when it comes to ordering diagnostic tests, keeping detailed records and doing follow-up.
The study's lead author, Dr. Tejal K. Gandhi, director of patient safety at Brigham and Women's Hospital in Boston, said the research shows that doctors could use more help in making decisions. Things that could help include more use of electronic records, better algorithms for making evaluations and the use of nurse practitioners to help ensure that follow-ups actually occur, she said.
"I don't want to say that it's not the physician's responsibility," Gandhi said. "We think there could be tools to help physicians make these decisions better."
The study looked at random samples of claims from four malpractice insurance companies throughout the U.S. The reviewers were instructed to ignore the outcomes of the claims, all of which closed between 1984 and 2004; nearly 60 percent of the cases resulted in serious harm and 30 percent resulted in death. All involved missed or delayed diagnoses in office settings.
Most of the errors occurred in doctor's offices and primary care physicians were those most frequently involved. More than half of the missed diagnoses involved cancer, primarily breast and colorectal cancer, and biopsies were the test most frequently at issue.
The researchers said the leading factors that contributed to errors included failures in judgment (79 percent), vigilance or memory (59 percent), knowledge (48 percent), patient-related factors (46 percent) and handoffs (20 percent).
"Communication issues are major issues," said Langston, a primary-care doctor in Lafayette, Ind. "The message is we need to take a hard look at what's happening and how can we decrease it."
"COLLABORATE FOR SUCCESS"
A Great Source for Information The above referenced text, published recently as part of the American College of Healthcare Executives Management Series, contains an excellent chapter entitled "Taking a Proactive, Collaborative Approach to Malpractice Issues." Authored by Andrew Feldman, Esq., a member of Academic's excellent panel of defense attorneys, it contains much current data and a sensible approach to many potential malpractice issues. We have found it to be a wonderful addition to the limited published information on this subject. We congratulate Mr. Feldman on this publication and recommend it highly.
SURGEONS VARY WIDELY IN THEIR APPROACHES TO DISCLOSING MEDICAL ERRORS TO THEIR PATIENTS
Surgeons are encouraged to fully disclose medical errors they make during the care of patients, yet few receive training on the best way to talk to patients about errors. Surgeons are also often reluctant to do so because of possible malpractice suits, discomfort in facing angry patients, and concern about potential damage to their reputation. A study, supported in part by the Agency for Healthcare Research and Quality (HS11898 and HS14012), analyzed how surgeons talk with patients about medical errors and found that the surgeons' approaches to these discussions varied widely.
Researchers randomly assigned 30 surgeons to meet with standardized patients, who portrayed patients in 3 different hypothetical error scenarios. The scenarios included a wrong-side lumpectomy related to a surgeon's error in labeling breast biopsy specimens, a retained surgical sponge after a splenectomy, and life-threatening hyperkalemia-induced cardiac arrhythmia related to the surgeon forgetting to check laboratory test results. The patients, who had experience in assessing physicians' communications skills, rated each encounter based on five communication elements of effective error disclosure.
The surgeon were rated highest on their ability to explain the medical facts about the errors (average scores for the three scenarios ranged from 3.93 to 4.20 out of a maximum score of 5). However, surgeons used the word "error" or "mistake" in only 57 percent of disclosure conversations. In 27 percent of cases, surgeons used the words "complication" or "problem" to describe the error.
Academic physicians are fortunate to have available a 24 hour "hot line" staffed with professionals that can guide physicians in having these conversations without increasing their risk of legal action. Academic subscribers may call 800-572-0179 to reach the law firm of Feldman, Kieffer & Herman, LLP, to gain advice in handling risk management questions.
The report cited above, "How surgeons disclose medical errors to patients: A study using standardized patients," by David K Chan, M.D., Thomas H. Gallagher, M.D., and Wendy Levinson, M.D., is in the November 2005 Surgery 138, pp. 851-858.
NEW YORK STATE LEGISLATURE PASSES SWEEPING HEALTH CARE FRAUD REFORM LEGISLATION
The New York State Legislature recently enacted tough new health care fraud provisions intended to strengthen the state's Medicaid enforcement efforts. This bill mandates the reorganization of the state's anti-healthcare-fraud system by creating an independent Medicaid inspector general's office that will oversee all Medicaid fraud detection, prevention, and recovery efforts. In addition, the legislation contains provisions directly affecting health care providers, including a requirement that virtually all Medicaid providers must implement a health care compliance program in accordance with the state's requirements. Finally, this bill creates new criminal offenses for health care fraud against public as well as private health care plans. Academic subscribers in New York should take note of this legislation because it not only will result in increased Medicaid fraud enforcement efforts but also will impose a new mandate regarding health care compliance programs that goes well beyond federal law.