Sunday, March 11, 2007

Clinical innovations - Innovative Strategies to Reduce Malpractice Risk

This article appeared in the February 7, 2007, edition of Physicians’ Weekly, a newsletter that appears in poster form in staff lounges and other physician gathering places in 1600 U.S. hospitals. The newsletter is estimated to be read by 250,000 physicians each week.

I submit it as a blog because reducing malpractice exposure remains an overriding concern among hospitals and physicians. Also I believe solutions to malpractice often reside in taking systematic, innovative steps to circumvent malpractice rather than in complaining about attorneys and campaigning for tort reform.

The article begins:

Focusing efforts on patient safety and education and identifying valuable resources can help practices reduce their risk of future medical malpractice claims and suits.

Medical malpractice claims are of great concern and are the basis by which many physicians make decisions on their choice of specialty right through to deciding on when and how to retire. According to Richard L. Reece, MD, there are many steps that physicians can take to reduce their risk of being involved in a malpractice claim (Table 1).

Table 1 --7 Steps to Reducing Malpractice Risks

By performing the following steps, physicians and practices from all backgrounds and specialties can reduce their risk of incurring malpractice suits.

1. Carefully document each patient encounter and do it electronically when possible.
2. Provide patients with a record of the details of their visit before they leave the office.
3. Communicate thoroughly via conversations and paper documentation.
4. Ensure that patients completely understand what they being told and have them repeat what was said.
5. Spot litigious patients. These individuals:
• Are more likely to have psychological problems.
• May present with information from the Internet.
• Often have a history of suing doctors.
• Are likely to have complex problems.
• Have a history of seeing multiple doctors.

6. Have patients sign informed consent forms and waivers to disclose that they will not sue for frivolous reasons.
7. Inform patients about their condition using patient education materials.

“While there are many things that can be done to lower the risk of malpractice suits,” he says, “the most important consist of identifying patients who are prone to such claims, practicing safe medicine, educating patients, incorporating risk-management systems into hospitals, and utilizing alternative-risk organizations.”

Tackling Patient Safety

According to Dr. Reece, being aware of patients who are prone to submitting malpractice claims is one of the key steps to avoiding them. “If physicians can spot potentially litigious patients, they are doing themselves a great service. These patients may have a history of suing physicians and are more likely to have psychological problems. Typically, this patient group presents with very complex problems. They’ll come in with information they obtained from the internet and may seek treatment from multiple doctors. If a patient demonstrates these characteristics, it’s important to carefully document the visit, communicate with the patient, and repeat what is said. Another helpful tactic is to have patients sign a consent form and waiver that they will not sue for frivolous reasons.”

Practicing safer medicine is another important aspect to reducing the risk of malpractice, adds Dr. Reece. “Throughout the past 20 years, anesthesiologists have taken measures to greatly improve the safety of their practice, including practicing procedures on mannequins and using pulse oximetry to measure blood oxygen levels and other devices to detect carbon dioxide levels. Taking similar precautions in practice settings can reduce your malpractice risk.”

Safe practices also need to be addressed in hospitals. Recently, the Institute of Medicine launched the “100,000 Lives Saved” campaign to lower the number of deaths that occur in hospitals; since its introduction, the campaign has been incorporated into about 3,000 hospitals. It includes six important measures that physicians and hospitals should follow to reduce malpractice (Table 2). Learning more about this campaign can provide valuable strategies and insights, according to Dr. Reece.

Table 2 - ^ Steps to Improving Patient Safety

The Institute of Healthcare Improvement’s “100,000 Lives Campaign” aims at reducing the number of annual deaths that occur in the hospitals. Six methods are cited as methods to improve hospital safety and patient outcomes.

1. Prevent ventilator-associated pneumonia (VAP). Simple maneuvers (, elevating the head of the hospital bed, frequently cleaning the patient’s mouth) can eliminate VAP.
2. Prevent IX-catheter infections: Adopt simple procedures for changing bandages around cathers and make sure no catheter remains in a vain longer than needed.
3. Stop surgical cite infections: Hospitals should give the appropriate antibiotics at the recommended time during surgery, enforce hand-washing practices, and avoid shaving the surgery cite before the operation.
4. Respond rapidly to early warnings: Setting up special-response teams can help hospitals to ensure that critical warnings are not missed or ignored. Take family members and nurses concerns seriously, and respond within minutes.
5. Make heart attack care reliable: Hospitals should ensure that every heart attack patient gets every treatment and medication recommended by the American College of Cardiology and other experts. These measures often include aspirin and beta-blocker therapy upon arrival and may require stent implementation or a clot-busting agent promptly after admission.
6. End medication errors: Reconcile medications whenever patients move from one care setting to another, even it it occurs within the hospital.

Patient Education Plays a Vital Role

Patient education is another important aspect of reducing the risk of malpractice suits, indicates Dr. Reece. “Managing patient expectations about their care is key, especially because many of these individuals have unrealistic ideas on what their procedure or treatment will entail. One group, Emmi Solutions, is now offering a new service to educate patients on exactly what to expect when entering the hospital for a procedure. This online resource allows physicians to register for and ‘prescribe’ detailed videos to their patients. Patients access the system with an account number provided by their doctor and view videos explaining what to expect in simple, sixth-grade reading level language. So far these videos have been incorporated into over 400 medical groups and used by approximately a half million patients; no malpractice claims have ensued.” Dr. Reece adds that this resource appears to be of great value because many claims can result largely from patient misunderstanding rather than physician negligence.

Risk Resources Help Manage Risks

Risk-management systems in hospitals also play a significant role in the fight against malpractice claims. “These systems consist of a dedicated manager to manage all aspects of risk within a hospital,” explains Dr. Reece. “Such duties may include credentialing doctors, filling out incident reports, following up on patient complaints, documenting claims, and educating physicians on sensitivity to patient complaints and offering apologies. We need to remember that apologies play a large role in malpractice; simply offering an apology and admitting that an error was made may reduce the number of malpractice claims.”

Physicians can also protect themselves against malpractice claims by enrolling in alternative-risk retention groups. “These groups are set up off shore,” Dr. Reece says, “but offer malpractice insurance to U.S. physicians. Such groups are necessary since finding American-based insurers is becoming increasingly difficult. Adding to the growing popularity of these groups is the fact that they offer the same coverage as conventional insurers but at a lower price.” While these groups can help lower the rising costs of malpractice claims, it is important to note that they are not yet accepted in all 50 states.

What Does the Future Hold?

The steps Dr. Reece discussed are important when assessing the risk for malpractice suits, and he says that simply initiating any one of these steps can help reduce risks. “Recent studies have shown that the rate of malpractice suits in the United States is leveling off. In order to keep this level steady and perhaps reduce it over time, following these simple steps is critical.”

Reference Links

For more information on Emmi Solutions, visit

Dr. Reece authored an article titled “Managing Malpractice Risk” that was published on the Hospitals & Health Networks website. To access the article, go to

Szalados JE. Legal issues in the practice of critical care medicine: A practical approach. Crit Care Med. 2007;35(2 Suppl):S44-S58.

Taheri PA, Butz DA, Anderson S, et al. Medical liability—The crisis, the reality, and the data: The University of Michigan story. J Am Coll Surg. 2006;203:290-296.

Vukmir RB. Medical malpractice: Managing the risk. Med Law. 2004;23:495-513.

Johnson WB 3rd. Managing risk in a risky world. J Miss State Med Assoc. 2003;44:219-224

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