The SCAHRM SOURCE Newsletter

COVERYS- Patient Safety Through the Lens of Malpractice Claims

July 2023

Patient Safety Through the Lens of Malpractice Claims

By Marlene Icenhower,

BSN, JD, CPHRM Maryann Small, MBA

Coverys is committed to supporting healthcare practitioners in enhancing their culture of safety, reducing risk, and improving patient safety. The World Health Organization estimates that 2.6 million deaths occur every year due to unsafe care in hospitals, and 40% of patients are harmed in the ambulatory care setting. Most of these events are preventable.

Medical error is the third-leading cause of death in the U.S. after heart disease and cancer. Despite the efforts of national and local patient safety organizations and institutional initiatives to enhance patient safety, those statistics haven’t really changed much over the years. Often, an organization will focus patient safety efforts based upon internal, facility-level data and trends that, while disturbing, may not result in patient harm.

To improve patient safety and quality in a meaningful fashion, it is important to understand and identify some of the most common patient safety issues that result in actual patient harm and the factors that contribute to them. One of the best ways to do this is to examine data from closed medical professional liability (MPL) claims. Coverys, a medical professional liability carrier, has analyzed claims data to uncover surprising trends that can enable organizations to laser-focus patient safety efforts. What does the current data tell us about patient safety issues among our policyholders?

A review of 6,559 closed events from 2015-2019 shows the three top patient safety issues that contribute to claims involve patient assessment (15%), technical performance during a surgery or procedure (12%), and documentation (9%). These key issues account for over one-third of all patient safety risks identified in recent Covery’s claims.

Patient assessment issues affect all clinical specialties and care settings. Inadequate patient assessment may result in failure to order appropriate tests, failure to create appropriate differential diagnoses and misinterpretation of test results. These vulnerabilities reduce the chance that the provider will accurately and timely diagnose a condition and increase the chance of complete misdiagnosis. Patient assessment issues begin at the time the patient presents to the office or hospital and can persist throughout the diagnostic, referral, and follow-up processes.

Consider the following risk management strategies to reduce diagnostic errors:

• Develop a policy for performing a history and physical that requires obtaining and documenting specific elements of the patient’s and family’s history and of the patient’s physical examination. Consider using a checklist.
• Establish a routine for regularly updating family history. Reminders and prompts in the electronic health record (EHR) will help establish consistent attention.
• Establish evidence-based policies and procedures regarding the frequency, content, and documentation of patient assessment/differential diagnosis.
• Educate providers regarding the use of available clinical decision support tools.
• Implement a formal process for reviewing and reporting critical lab values/results and time-sensitive reports to the appropriate practitioner.
• Implement a process for communicating test reports and lab values to patients along with information about whom to contact for clarification.
• Develop a consultation policy that includes criteria to help practitioners decide whether to obtain a consultation, when a consultation is essential, and when a consultant must directly manage the patient.
• Ensure that a computer provider order entry (CPOE) system (or other electronic prescribing system) includes activated alert systems.

Technical performance issues primarily affect surgeons and any provider performing invasive procedures. Unexpected complications from routine procedures can result in adverse outcomes, especially if the patient’s comorbid conditions are not factored into the plan. In addition, skill-based issues result in poor clinical decision-making, which also affects patient outcomes. Technical performance issues are best addressed by applying consistent credentialing and privileging processes and well-designed surgical/procedural processes.

Consider the following risk management strategies to reduce the incidence of technical error in your organization:

• Establish credentialing and privileging policies and procedures to ensure that only competent providers practice within the organization. Confirm that those policies and procedures are consistent with regulatory requirements, accreditation standards, and the organization’s rules and regulations.
• Develop a process for determining the appropriate privileges to grant an individual practitioner and a mechanism for assessing maintenance of competency that reflects the service offerings of the organization.
• Develop a formal process for assessing the competency of new practitioners, practitioners requesting new privileges, or practitioners whose competency is in question.
• Develop a process for ongoing evaluation of healthcare practitioners’ continued competency to meet the standard of care, as well as their compliance with the organization’s rules and regulations.
• Ensure that a review process is in place for evaluating the delivery of care provided by medical staff members that includes case review, analysis of physician performance data, and a process for reporting and identifying performance improvement activities.
• Standardize practice protocols, policies, and procedures to conform with evidence-based guidelines and recommendations of professional organizations and licensure, regulatory, and accreditation bodies.
• Review Universal Protocol policies and procedures to ensure they address the pre-procedure verification process, which includes marking the procedure site and performing a “timeout” immediately prior to starting the procedure.
• Review preoperative policies and procedures to ensure they address documentation of preoperative physical assessment/history and physical and informed consent.

Documentation issues also comprise a top risk factor in MPL claims affecting all clinicians and care settings. One of the medical record’s primary functions is to communicate clinically pertinent information to those involved in patient care. Basing treatment decisions on incomplete, missing, or inaccurate information often results in patient harm. To make the record an effective communication avenue among clinicians, it should be structured to provide a user-friendly means to document the flow of patient care. The record should not only capture but also correlate pertinent information for clinical decision-making.

Documentation also serves an evidentiary function. In the event of a lawsuit, inadequate or sloppy documentation can create an inference of poor medical care in the minds of a jury. As paper records become less common, the EHR has created new risks for practitioners. Poor design, lack of training, and time constraints create problems for clinicians who fail to adequately document support for their decisions and actions in the patient record.

Consider the following strategies to enhance documentation quality in your organization:

• Develop templates to prompt clinically pertinent assessment, intervention, communication, and documentation for clinical presentations that commonly present or are high-risk.
• Provide formal training on EHR documentation to physicians and other clinical staff upon hire and at regular intervals. Consider including the following in training:
  • Reviewing documentation fundamentals, such as legibility, accuracy, addendums/alteration, timeliness, objectivity.
  • Charting by exception guidelines (e.g., checking boxes to indicate “normal” findings). Adding late entries, addendums.
  • Using the copy/paste function, templates, and drop downs appropriately. Guarding against incorrect entries (e.g., documentation on the wrong patient). Navigating the record to locate documentation by other disciplines.
  • Documenting informed consent/refusal. Use acceptable abbreviations.
  • Using voice recognition software.
• Review organizational rules and regulations to ensure that they address medical record documentation requirements (e.g., countersignatures, verbal orders, length of time to dictate postoperative notes).
• Ensure that policies and procedures address physician order entry, including verbal/telephone orders and CPOE use.
• Address appropriate, timely documentation individually and as part of the performance evaluation process for all clinicians.
• Establish a formal quality audit process to monitor compliance with documentation policies and procedures/best practices and to identify opportunities for improvement.
• Consider using medical scribes to improve documentation quality and increase physician productivity.

Safety in the healthcare setting should be a priority for all organizations. Patient safety improvement efforts are essential in our journey to zero harm, but when they are data-driven, they can produce meaningful, measurable results.