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PubMed2005

Effects of a malpractice crisis on specialist supply and patient access to care.

OBJECTIVE: To investigate specialist physicians' practice decisions in response to liability concerns and their perceptions of the impact of the malpractice environment on patient access to care. SUMMARY BACKGROUND DATA: A perennial concern during "malpractice crises" is that liability costs will drive physicians in high-risk specialties out of practice, creating specialist shortages and access-to-care problems. METHODS: Mail survey of 824 Pennsylvania physicians in general surgery, neurosurgery, orthopedic surgery, obstetrics/gynecology, emergency medicine, and radiology eliciting information on practice decisions made in response to rising liability costs. RESULTS: Strong majorities of specialists reported increases over the last 3 years in patients' driving distances (58%) and waiting times (83%) for specialist care or surgery, waiting times for emergency department care (82%), and the number of patients forced to switch physicians (89%). Professional liability costs and managed care were both considered important contributing factors. Small proportions of specialists reported that they would definitely retire (7%) or relocate their practice out of state (4%) within the next 2 years; another third (32% and 29%, respectively) said they would likely do so. Forty-two percent of specialists have reduced or eliminated high-risk aspects of their practice, and 50% are likely to do so over the next 2 years. CONCLUSIONS: Our data suggest that claims of a "physician exodus" from Pennsylvania due to rising liability costs are overstated, but the malpractice situation is having demonstrable effects on the supply of specialist physicians in affected areas and their scope of practice, which likely impinges upon patients' access to care.

Career Choice↗

PubMed2006

Transparent and open discussion of errors does not increase malpractice risk in trauma patients.

OBJECTIVE: We set out to determine if there is an increased medical malpractice lawsuit rate when trauma patient cases are presented at an open, multidisciplinary morbidity and mortality conference (M&M). INTRODUCTION: Patient safety proponents emphasize the importance of transparency with respect to medical errors. In contrast, the tort system focuses on blame and punishment, which encourages secrecy. Our question: Can the goals of the patient safety movement be met without placing care providers and healthcare institutions at unacceptably high malpractice risk? METHODS: The trauma registry, a risk management database, along with the written minutes of the trauma morbidity and mortality conference (M&M) were used to determine the number and incidence of malpractice suits filed following full discussion at an open M&M conference at an academic level I trauma center. RESULTS: A total of 20,749 trauma patients were admitted. A total of 412 patients were discussed at M&M conference and a total of seven lawsuits were filed. Six of the patients were not discussed at M&M prior to the lawsuit being filed. One patient was discussed at M&M prior to the lawsuit being filed. The incidence of lawsuit was calculated in three groups: all trauma patients, all trauma patients with complications, and all patients presented at trauma M&M conference. The ratio of lawsuits filed to patients admitted and incidence in the three groups is as follows: All Patients, 7 lawsuits/20,479 patients (4.25 lawsuits/100,000 patients/year); M&M Presentation, 1 lawsuit/421 patients (29.6 lawsuits/100,000 patients/year); All Trauma Complications, 7 lawsuits/6,225 patients (14 lawsuits/100,000 patients/year). Patients with a complication were more likely to sue (P < 0.01); otherwise, there were no statistical differences between groups. CONCLUSIONS: A transparent discussion of errors, complications, and deaths does not appear to lead to an increased risk of lawsuit.

Humans↗

PubMed2005

Analysis of diagnostic error in paid malpractice claims with substandard care in a large healthcare system.

OBJECTIVE: Although claims databases are not representative of all care delivery, their predisposition toward serious unintended injury can complement resource-intensive chart reviews and guide patient safety initiatives. MATERIALS AND METHODS: Non-Veterans Health Administration (VA) practitioners reviewed 1,949 VA malpractice claims paid during fiscal years 1998 through 2003. The portion associated with substandard care, the severity of harm, and types of negligence were identified. RESULTS: Negligent adverse events occurred in 37% (n = 723) of paid VA malpractice claims. These had high proportions of serious injury (55%) and morbidity (37%). Diagnostic negligent adverse events were most frequent (45%) and with 41% associated morbidity. The annual incidence of diagnosis-related paid VA malpractice claims was 1.95 per 100,000 patients and predicts that 122 of every 100,000 patients may have diagnostic negligent adverse events. Comparisons against non-VA data suggest this to be a healthcare industry problem. CONCLUSIONS: Diagnosis-related negligent adverse events are a serious problem in the healthcare industry.

Diagnostic Errors↗

PubMed1988

Medical malpractice claims in obstetrics and gynaecology: comparisons between the United States and Britain.

Obstetricians and gynaecologists have been particularly affected by the increase in the cost and number of medical malpractice claims in Britain. US obstetricians and gynaecologists have experienced a disproportionately higher rate of claim than other practitioners in that country. This article reviews the US experience of obstetrics and gynaecology malpractice claims and questions the validity of showing comparisons between the US and UK. However, even if British malpractice claims do not reach the level of American claims, the effects of claims on the National Health Service, recruitment to obstetrics and gynaecology, and clinical practice are significant.

Female↗

PubMed1989

The malpractice crisis. Relevance for geriatrics.

The adverse effects of the current American medical malpractice problem on the practice of geriatric medicine have thus far been relatively minor, but real. This article discusses some of the prominent public policy issues involved in the ongoing debate about malpractice, with special application to older patients and their physicians. Suggestions are made for appropriate actions by geriatricians individually and collectively, in response to the malpractice situation.

Age Factors↗

PubMedDate not supplied

Strategies for reducing the risk of malpractice litigation in perinatal nursing.

Perinatal nurses are involved in malpractice litigation most often as employees of a hospital being sued. Contemporary case examples from malpractice claims provide the foundation for examining how perinatal nurses can become the focus of such litigation. Increasing demand for individual nurse accountability, cost containment strategies that require nurses to broaden their scope of practice and to supervise unlicensed assistive personnel, increasing use of medical technologies, and the reality of compromised newborns and unexplained outcomes place perinatal nurses at risk for continued malpractice vulnerability. Specific strategies for risk reduction can be used by the individual nurse and the institution in relation to hospital policies and procedures, application of the nursing process, documentation, birth videos, and delegation of tasks to unlicensed assistive personnel.

Communication↗

PubMed2004

Malpractice, tort reform, and you: an introduction to risk management.

The current malpractice crisis has been called the "perfect storm". Doctors are finding practice costs unsustainable. Patients are finding access to care jeopardized. Cost of care is escalating. The system does not deter medical error, compensate most injured victims, produce any result quickly. These factors are creating enough of a crisis to urgently address and merit prompt solution. However, if history is any guide, the debate over malpractice will continue to rage. Reforms will likely be slow. Thus the practicing gastroenterologist, while working for or supporting efforts toward a solution, is well advised to keep up to date with the practice of gastroenterology, but also understand the medical legal matters and have a risk management strategy that will hopefully help keep the malpractice crisis a theoretical rather than personal concern. The following articles in this series are intended to help.

Compensation and Redress↗

PubMed1999

Impact of physicians' perceptions of malpractice and adaptive changes on intention to cease obstetrical practice.

Physicians who provide obstetrical care in rural areas face exposure to liability action and confront a critical decision--whether to continue to offer these services. This paper draws upon social-psychological and decision theories to investigate this decision. Ninety-four percent of all obstetricians and family and general physicians practicing in the 12 nonmetropolitan counties of one state responded to a mail survey that asked about their intention to continue or discontinue obstetrical practice, two dimensions of subjective risk (perceived likelihood of threats in the malpractice environment and perceived magnitude of negative consequences from being sued), and adaptive changes to protect against malpractice. The results suggest that (a) perceived extent of negative consequences (but not perceived likelihood of malpractice threats) drives intention to leave obstetrics, (b) the professional and reputational impacts of a suit--not the dollar amount of award or settlement--predicts intention to stop practicing obstetrics, and (c) physicians planning to continue providing obstetrical care in the future have made recent practice changes that may further exacerbate access problems.

Adult↗

PubMed2004

Learning from malpractice claims about negligent, adverse events in primary care in the United States.

BACKGROUND: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. METHODS: Physician Insurers Association of America malpractice claims data (1985-2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. RESULTS: Of 49345 primary care claims, 26126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). CONCLUSIONS: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.

Health Services Research↗

PubMedDate not supplied

Commentary: Exploiting the overlap: using utilization management to reduce medical malpractice.

This report presents a practical way in which hospitals can reduce medical malpractice exposure that is related to omissions and delays in care. We illustrate our approach using the results of a risk/medical management study performed at an acute-care hospital. Traditional risk management (RM) often focuses retrospectively on adverse events and may miss opportunities to prevent errors related to omissions and delays in care. Close-to-real-time utilization management (UM) activity offers ready potential to improve quality and reduce medical malpractice--but only if UM can work synergistically with RM. It is our conclusion that hospitals can implement systematic processes to identify and intervene in patterns of omissions and delays and improve the communication and synergy among stakeholders and thereby improve patient safety and reduce their medical malpractice risks.

Communication↗

PubMedDate not supplied

Strategic risk management: reducing malpractice claims through more effective patient-doctor communication.

Many malpractice suits are brought not because of malpractice nor even because of complaints about the quality of medical care but as an expression of anger about some aspect of patient-doctor relationships and communications. The theory presented is that under the stress of anxiety and physical illness, some patients regress to childhood needs; physicians are not generally trained to fill such needs. Thus, these patients, angry because of this, express their anger in malpractice suits. This theory has been taught to physicians and medical students as part of a physician continuing medical education (CME) seminar on Loss Prevention/Risk Management through demonstration of active-listening techniques to seminar participants. Physicians who understand and can respond appropriately to the emotional needs of their patients are less likely to be sued. This may also translate into a more fulfilled practice of medicine by those physicians who are most aware of the importance of a positive relationship.

Anger↗

PubMed1989

Can no-fault compensation of impaired infants alleviate the malpractice crisis in obstetrics?

In 1987, Virginia initiated no-fault compensation for birth-related neurological injuries in an attempt to ensure the availability of malpractice insurance for the state's obstetricians. This paper explores some possible causes for the refusal of Virginia's insurers to write malpractice coverage for obstetricians and analyzes the ability of the act to resolve the medical malpractice crisis in obstetrics. It also examines the effect of this limited no-fault compensation scheme on obstetricians' incentives and on the welfare of neurologically damaged children.

Birth Injuries↗

PubMed1996

Medical malpractice in Michigan: an economic analysis.

We analyzed the factors determining the amount of the recovery on claims based on medical malpractice. Our data set, which previously was not explored, consists of 20,428 claims arising within Michigan that were closed between 1978 and 1990. During this period, major changes were made in the law governing malpractice litigation. We determine the effect of these changes and of various other factors affecting medical malpractice claims. We analyze the effect of a statute that was designed to curtail "forum shopping" by attorneys for plaintiffs. This statute was initially successful in curbing such activity, but its effect seems to be diminishing. In addition, we compare mediation awards with settlement payments, and settlement payments with the expected value of claims in litigation. Evidence suggests that a mediation award is the mediation panel's estimate of a settlement payment appropriate for the case, and that cases are settled for substantially less than their expected value at trial.

Health Care Reform↗

PubMedDate not supplied

The medical malpractice 'crisis': recent trends and the impact of state tort reforms.

By many accounts, the United States is in the midst of its third medical malpractice "crisis." Physicians in several states are facing high and rising premiums. The largest national medical malpractice carrier and some large multistate physician-backed liability firms have recently left the market. Rising premiums are traced largely to increases in claims severity. Capping malpractice payments has been advanced as one approach to slowing the growth in premiums. This analysis finds that premiums in states that cap awards are 17.1 percent lower than in states that don't cap. At issue, however, is whether these stopgap solutions promote the goals of the U.S. liability system.

Insurance, Liability↗

PubMedDate not supplied

The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank.

We used data from the National Practitioner Data Bank (NPDB) to study the growth of physician malpractice payments. Judgments at trial account for 4 percent of all malpractice payments; settlements account for the remaining 96 percent. The average payment grew 52 percent between 1991 and 2003 (4 percent per year) and now exceeds dollar 12 per capita each year. These increases are consistent with increases in the cost of health care. A preoccupation with data on judgments, extreme awards, or specific specialties results in an incomplete understanding of the growth of physician malpractice payments.

Costs and Cost Analysis↗

PubMed2001

American Academy of Pediatrics: Technical report: Alternative dispute resolution in medical malpractice.

The purpose of this technical report is to provide pediatricians with an understanding of past crises within the professional liability insurance industry, the difficulties of the tort system, and alternative strategies for resolving malpractice disputes that have been applied to medical malpractice actions. Through this report, pediatricians will gain a technical understanding of common alternative dispute resolution (ADR) strategies. The report explains the distinctions between various ADR methods in terms of process and outcome, risks and benefits, appropriateness to the nature of the dispute, and long-term ramifications. By knowing these concepts, pediatricians faced with malpractice claims will be better-equipped to participate in the decision-making with legal counsel on whether to settle, litigate, or explore ADR options.

Liability, Legal↗

PubMed1998

1996 congressional campaign priorities of the AMA: tackling tobacco or limiting malpractice awards?

OBJECTIVES: This study sought to determine whether the political action committee of the American Medical Association (AMA) contributed more to pro- or anti-tobacco members of Congress in the 1995/96 campaign and whether representatives' voting records on malpractice reform could explain the AMA's contribution patterns. METHODS: Campaign contributions to House members were analyzed. RESULTS: The AMA's political action committee contributed averages of $5382 to pro-tobacco representatives and $2103 to anti-tobacco representatives (P < .0005). This contribution pattern can be fully explained by representatives' votes to limit malpractice awards. CONCLUSIONS: In seeking malpractice reform, the AMA contributed significantly more to pro-tobacco representatives, potentially undermining tobacco control legislation.

Adolescent↗

PubMed1996

Professional defenses: medical students' perceptions of medical malpractice.

Despite the pronounced interest in "challenges to professional dominance" in Britain, medical malpractice has been subject to little empirical attention. There has been a flurry of policy activity within the National Health Service over the last six or so years and a steady stream of commentary from professional bodies, yet we know very little about the views of various medical practitioners who occupy different positions in the professional hierarchy. This article explores the views of (first and fifth year) medical students and considers the extent to which they cohere with the public discourse of medical elites. The author suggests that while individual practice is the focal concern for medical students who seem acutely aware and concerned about litigation, elites construct malpractice as a macro economic-legal problem, strategically severing the association between individual practice and the experience of a malpractice suit.

Adolescent↗