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This article is the fourth in a series addressing the structuring of group medical practice entities, shareholder relationships, and general representation factors. In this article, important considerations relating to liability insurance and pension plans, and both the phasing in and phasing out of shareholders are discussed.
The malpractice world is changing, and physicians are asking: How do I choose the right carrier for me? To help physicians answer that and related questions, the chairman of the board of the Society's liability insurance company offers this overview of the company's basic philosophy and focus.
BACKGROUND: The relative importance of the different factors that cause surgical error is unknown. Malpractice claim file analysis may help to identify leading causes of surgical error and identify opportunities for prevention. METHODS: We retrospectively reviewed 444 closed malpractice claims, from 4 malpractice liability insurers, in which patients alleged a surgical error. Surgeon-reviewers examined the litigation file and medical record to determine whether an injury attributable to surgical error had occurred and, if so, what factors contributed. Detailed descriptive information concerning etiology and outcome was recorded. RESULTS: Reviewers identified surgical errors that resulted in patient injury in 258 of the 444 (58%) claims. Sixty-five percent of these cases involved significant or major injury; 23% involved death. In most cases (75%), errors occurred in intraoperative care; 25% in preoperative care; 35% in postoperative care. Thirty-one percent of the cases had errors occurring during multiple phases of care; in 62%, more than 1 clinician played a contributory role. Systems factors contributed to error in 82% of cases. The leading system factors were inexperience/lack of technical competence (41%) and communication breakdown (24%). Cases with technical errors (54%) were more likely than those without technical errors to involve errors in multiple phases of care (36% vs 24%, P = .03), multiple personnel (83% vs 63%, P < .001), lack of technical competence/knowledge (51% vs 29%, P < .001) and patient-related factors (54% vs 33%, P = .001). CONCLUSIONS: Systems factors play a critical role in most surgical errors, including technical errors. Closed claims analysis can help to identify priority areas for intervening to reduce errors.
OBJECTIVE: This study was undertaken to document and generalize the professional liability insurance (PLI) crisis. STUDY DESIGN: Data analysis from physician surveys, Missouri Department of Insurance, and court records. RESULTS: In 2001-2002, many insurers stopped writing new and existing PLI. A survey found 1 in 7 physicians had their PLI terminated and/or application for new insurance denied. Average premiums increased 22% in 2001 and 60% in 2002. Accordingly, 50% of surveyed obstetricians took salary cuts, 18% secured loans, 9% liquidated assets, and 55% significantly limited their clinical services. An adverse court ruling caused insurers to double reserves. Incomplete data led the Missouri Department of Insurance to erroneously conclude a decrease in claim frequency and severity. In contrast, courthouse records and missing data sources revealed increased malpractice filings. PLI premiums continue to rise. CONCLUSION: Many life-saving specialists are being forced out of business. Specialists are less willing to care for emergency and indigent patients for fear of liability exposure. Legislative enactments leading to meaningful tort reform, public support, and judicial restraint must occur to save health care.
Since the number of lawsuits involving consultants has increased in recent years, it is important for clinical nurse specialists to be aware of the causes for these lawsuits and to protect themselves from the possibility of litigation. Maintaining open communication with clients, using an evaluation tool as a means for ensuring quality, drawing up a legal contract, and carrying adequate liability insurance are four important ways to protect oneself from the possibility of legal action.
INTRODUCTION: The authors' residency program implemented a one-week rotation at the office of a medical liability insurance company. Residents examined 30 closed malpractice claims cases and sat in on settlement discussions. OBJECTIVE: To review the residents' evaluations of their experiences and to determine whether this was a worthwhile addition to the emergency medicine (EM) residency curriculum. METHODS: This was a five-year retrospective study that reviewed residents' annual evaluations from 1994 to 1999 regarding the medical liability rotation. A five-point scale was used to score specific categories in the rotation and an open-ended section was used to collect general comments. RESULTS: A total of 179 resident evaluations were reviewed. The quality of teaching ranked in the 80th percentile, the clinical caseload ranked in the 85th percentile, and level of responsibility ranked in the 79th percentile for all EM rotations. Specific comments included "All MDs should do this in their training"; "Quite an eye opener"; and "Good exposure to legal aspects of EM." CONCLUSIONS: Overall, EM residents found the one-week rotation to be invaluable and a good learning experience. This rotation ranked above average when compared with all of our other EM residency rotations.
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The medical malpractice business, as with the property and casualty industry as a whole, is cyclical in nature. We have experienced peaks and valleys since the mid-1970s. History would tell us that profitability can be restored in time. Many in the professional liability insurance industry think that a return to stability is possible by 2004. The two most critical factors in restoring this profitability may be adequate pricing and tort reform--time will tell the story.
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STUDY OBJECTIVES: Diagnostic errors in the emergency department (ED) are an important patient safety concern, but little is known about their cause. We identify types and causes of missed or delayed diagnoses in the ED. METHODS: This is a review of 122 closed malpractice claims from 4 liability insurers in which patients had alleged a missed or delayed diagnosis in the ED. Trained physician reviewers examined the litigation files and the associated medical records to determine whether an adverse outcome because of a missed diagnosis had occurred, what breakdowns were involved in the missed diagnosis, and what factors contributed to it. Main outcome measures were missed diagnoses, process breakdowns, and contributing factors. RESULTS: A total of 79 claims (65%) involved missed ED diagnoses that harmed patients. Forty-eight percent of these missed diagnoses were associated with serious harm, and 39% resulted in death. The leading breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (58% of errors), failure to perform an adequate medical history or physical examination (42%), incorrect interpretation of a diagnostic test (37%), and failure to order an appropriate consultation (33%). The leading contributing factors to the missed diagnoses were cognitive factors (96%), patient-related factors (34%), lack of appropriate supervision (30%), inadequate handoffs (24%), and excessive workload (23%). The median numbers of process breakdowns and contributing factors per missed diagnosis were 2 and 3, respectively. CONCLUSION: Missed diagnoses in the ED have a complex cause. They are typically the result of multiple breakdowns in the diagnostic process and several contributing factors.
BACKGROUND: Physicians who offer firearms counseling may increase their legal liability, depending on the attitudes of their medical malpractice insurance carriers. METHODS: A survey was mailed to the 100 largest medical malpractice insurers. Requested data included their experience with claims involving allegations of negligent firearm counseling by physicians, their opinion regarding whether firearm counseling by physicians would be covered under their medical malpractice policies, and their prediction of how their insurance group or company would handle such claims. RESULTS: Fourteen surveys were returned. No respondents reported having dealt with a case involving an allegation of negligent firearm counseling by a physician. Eight respondents (57%) thought that such counseling would not be covered under their medical malpractice policy, whereas six respondents (43%) said that it would. CONCLUSION: A majority of responding insurers thought that physician firearm counseling would not be covered under their medical malpractice policies. Physicians wishing to counsel their patients about the risks and benefits of owning and using firearms are advised to seek assurance of medical malpractice insurance coverage from their insurers or the annexation of a rider to their current policies.
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The year 1983 brings with it expanded coverage in the directors and officers liability policies offered to hospitals. In this article, the author discusses the impact of this added protection in terms of who and what is now covered.
Surveys of malpractice insurers and state insurance commissioners in 1992 show a highly concentrated market with opportunities for greater competition. Fewer than 50 firms write coverage nationally. Weighted premiums for $1 million/$3 million coverage vary across U.S. census divisions from $1,700 in the South to $3,000 in the Northeast. These data may be of interest to practitioners who purchase insurance and will aid dental associations in effectively participating in revisions of malpractice liability statutes as part of overall health care reform.
Physicians typically carry virtually complete malpractice insurance coverage. This contradicts standard theoretical predictions that under a negligence rule of liability there should be no demand for insurance, and insurance policies under moral hazard will contain co-payment provisions. It is argued that judicial 'errors' in defining negligence generate a demand for liability and legal defense insurance. Physician co-payment undermines the insurer's incentives for legal defense and thus induces a trade-off between loss reduction by injury prevention and by legal defense. Fee-for-service reimbursement further distorts the physician's choice between injury prevention and insurance. Implications for the deterrent function of the tort system are discussed.
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Practice parameters are here to stay and will have, in fact already have had, a dramatic effect upon the practice of medicine. The effect of practice parameters upon professional liability and professional liability carriers is uncertain.
Every crisis presents an opportunity, and today's med-mal insurance squeeze is no exception. Forced to seek innovative solutions or lose essential physician services, hospitals are finding that sponsoring liability coverage for doctors can pay off. Such sponsorship provides leverage to engage physicians in comprehensive risk-management programs.