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2007 study of medical malpractice claims

2007 study of medical malpractice claims

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2007 study of malpractice claims nationwide shows lax oversight of resident doctors puts patients at risk for medical errors.


2007 study of malpractice claims nationwide shows lax oversight of resident doctors puts patients at risk for medical errors.


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Published by: The Dallas Morning News on Jul 30, 2010
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ORIGINAL INVESTIGATION
Medical Errors Involving Trainees
 A Study of Closed Malpractice Claims From 5 Insurers
Hardeep Singh, MD, MPH; Eric J. Thomas, MD, MPH; Laura A. Petersen, MD, MPH; David M. Studdert, LLB, ScD, MPH
Background
:
Despite wide recognition that the deliv-ery of medical care by trainees involves special risks, in-formation about the types and causes of medical errorsinvolving trainees is limited. To describe the character-istics of and factors contributing to trainee errors, weanalyzed malpractice claims in which trainees were judged to have played an important role in harmfulerrors.
Methods
:
The claims were closed between 1984 and2004, and the errors occurred between 1979 and 2001.Specialistphysiciansreviewedrandomsamplesofclosedmalpractice claim files at 5 liability insurers from 2002to 2004 and determined whether injuries had occurred,and if so, whether they were due to error. We describedthe clinical circumstances and contributing factors as-sociatedwithharmfulerrorsinvolvingtrainees(“cases”). Wealso comparedthecharacteristicsofcaseswiththeirnontrainee counterparts and probed trainee errors at-tributedtoteamworkproblemsandlackoftechnicalcom-petence or knowledge.
Results
:
Among 240 cases, errors in judgment (173 of 240[72%]),teamworkbreakdowns(167of240[70%]),andlackoftechnicalcompetence(139of240[58%])werethe most prevalent contributing factors. Lack of super-vision and handoff problems were most prevalent typesof teamwork problems, and both were disproportion-ately more common among errors that involved train-ees than those that did not (respectively, 54% vs 7%[
P
.001] and 20% vs 12% [
P
=.009]). The most com-mon task during which failures of technical compe-tence occurred were diagnostic decision making andmonitoringofthepatientorsituation.Traineeerrorsap-peared more complex than nontrainee errors (mean of 3.8 contributing factors vs 2.5 [
P
.001]).
Conclusions
:
In addition to problems with handoffs,house staff are particularly vulnerable to medical errorsowing to teamwork failures, especially lack of supervi-sion. Graduate medical education reform should focuson strengthening these aspects of training.
 Arch Intern Med. 2007;167(19):2030-0
G
RADUATE MEDICAL EDU
-cationposesuniquechal-lengesforthedeliveryof safe patient care,
1-3
andmedicaltraineesfacespe-cial risks of involvement in medical er-rors.
4-10
This is predictable: trainees areinexperienced, often fatigued, and occa-sionally unsupervised, and the academicmedical centers in which they work aretypically large and complex facilitiescharged with treating the sickest pa-tients.Despiterecognitionoftheseriskfac-tors, information about the types andcauses of trainee errors is limited.
8
Thisknowledge gap inhibits the design of ef-fective prevention strategies, such as tar-geted educational programs and systemchanges to reduce trainee errors and ad-vance patient safety.
11
An improved un-derstanding of the causes of trainee er-rorscouldhelpguidetheimplementationof the Accreditation Council for Gradu-ate Medical Education’s (ACGME) corecompetencies into residency curricula indirections that advance patient safety.
2
TheMalpracticeInsurersMedicalErrorPrevention Study (MIMEPS), a review of 1452 malpractice claims from 5 insurers,provided us with a valuable opportunitytoinvestigatetraineeinvolvementinmedi-cal errors.
12
 We conducted a subanalysisof the MIMEPS claims in which studyreviewers detected harmful errors and judged that 1 or more interns, residents,orfellowsplayedanimportantcausalrole.Ourmaingoalsweretodescribethechar-acteristics of these “trainee errors” andidentifytheircontributingfactors.Wean-
For editorial commentsee page 2025
Author Affiliations
are listed atthe end of this article.
(REPRINTED) ARCH INTERN MED/VOL 167 (NO. 19), OCT 22, 2007 WWW.ARCHINTERNMED.COM
©2007 American Medical Association. All rights reserved.
 on April 13, 2010www.archinternmed.comDownloaded from 
 
ticipated that problems of technical competence, hand-off,
13
andotheraspectsofteamwork
14
wouldfigurepromi-nently, so we explored these areas in depth.
METHODS
STUDY SITES
Fivemalpracticeinsurancecompaniesin4regions(northeast-ern,mid-Atlantic,southwestern,andwesternUnitedStates)par-ticipated in the study. The companies covered approximately33000 physicians, 61 acute care hospitals (35 academic and26 nonacademic),and428 outpatientfacilities.Thestudywasapproved by ethics review boards at the investigators’ institu-tions and by the review sites.
CLAIMS SAMPLE
Datawereextractedfromrandomsamplesofclosedclaimfilesateachinsurerinon-sitereviewsconductedbetween2002and2004. The claim file is the repository of information accumu-lated by the insurer during the life of a claim. While the claimis open, it includes medical records pertaining to the episodeof care at issue. For all sampled claims, we reacquired the rel-evant medical records from insured institutions. We defined a claim as a written demand for compensationformedicalinjury.
15,16
 Wefocusedon4clinicalcategories—(1)obstetric,(2)surgical,(3)missedanddelayeddiagnoses,and(4)medication—andappliedauniformdefinitionofeachacrosssites.These categories cover approximately 80% of all medical mal-practice claims filed in the United States.
17,18
Insurers contrib-uted to the study sample in proportion to their annual claimsvolume.Thenumberofclaimsbysitevariedfrom84to662(me-dian, 294).
STUDY INSTRUMENTS AND CLAIM FILE REVIEW
Reviewers were board-certified attending physicians, fellows,or final-year residents in surgery (surgical claims), obstetrics(obstetricclaims),andinternalmedicine(diagnosisandmedi-cation claims). Physician investigators from the relevant spe-cialties trained the reviewers in the content of claims files, useofthestudyinstruments,andconfidentialityproceduresin1-daysessions at each site. Reviews took a mean of 1.6 hours per fileand were conducted by 1 reviewer.A sequence of 4 instruments guided the review. The reviewprocess has been described in detail in previous publica-tions.
12,19
Insummary,reviewersmadeaninitialjudgmentaboutwhether an adverse outcome had occurred, and if it did, theyscored the outcome on a severity scale ranging from emotionalinjury to death.
20
For claims with identifiable adverse out-comes,reviewers proceededto considerthepotentialcontribu-tory role of 17 possible contributory factors in causing the ad-verseoutcome.Next,theyjudgedwhethertheadverseoutcomewas due to medical error, defined as “the failure of a plannedactiontobecompletedasintended(i.e.,errorofexecution)ortheuse of a wrong plan to achieve an aim (ie, error of planning).”
21
Reviewers’ confidence in the error judgments was recorded ona6-pointscalerangingfrom1(littleornoevidencethatadverseoutcome resulted from error/errors) to 6 (virtually certain evi-dencethatadverseoutcomeresultedfromerror/errors).
22,23
Claimsthat scored 4 (more likely than not that an adverse outcome re-sulted from error/errors; more than 50-50 but a close call) orhigherwereclassifiedasinvolvinganerror.Finally,forthesub-setofclaimsjudgedtoinvolveanadverseoutcomeduetoerror,reviewersgathereddetailsoftheclinicalcircumstances,includ-ingthespecialtyofinvolvedcliniciansandtheircontributoryroleasratedona5-pointscale(1,somewhatimportant,to5,highlyimportant).To test the reliability of the claims file review, 10% of thefiles were rereviewed by a second physician from the relevantspecialty who was unaware of the first review. On the basis of 148 pairs of reviews,
scores were 0.78 (95% confidence in-terval,0.65-0.90)forthedeterminationofinjuryand0.63(95%confidenceinterval,0.12-0.74)forthejudgmentthaterroroc-curred. More detailed results of the reliability testing are re-ported elsewhere.
12,19,24
TRAINEE SAMPLE
TheunitofanalysisinMIMEPSwastheepisodeofcareinclaims judged to involve errors that led to an adverse outcome. Forease of exposition, we henceforth refer to such episodes as“cases.” For this study, we drew a subsample of cases from thefull sample of cases identified in MIMEPS (n=889). The sub-sample consisted of cases in which the reviewer had rated thecontributory role of a medical student, intern, resident, or fel-low at 4 or 5 or rated it 3 and no other involved clinician hada higher rating. Reliability testing for the determination that 1or more trainees were involved, which was based on 47 pairsof original reviews, showed good agreement (89% agreement;
=0.64 [95% confidence interval, 0.34-0.94]).
STATISTICAL ANALYSIS
AnalyseswereconductedusingtheStata/SE8.0(StataCorp,Col-lege Station, Texas) software package. We generated descrip-tive statistics to examine the characteristics of the trainees, pa-tients,andadverseoutcomesinthestudysample.Wecomparedthe frequency with which contributing factors were associatedwithtraineeerrorsvsnontraineeerrorsusingFisherexacttests. Weconductedanin-depthanalysisofcasesinvolvingprob-lemsofteamworkandtechnicalcompetence,respectively.Withrespect to teamwork problems, we investigated the personnelrelationshipsinwhichtheyoccurred.Caseswithteamworkprob-lems were defined as those in which the original reviewer had judgedthat1ormoreofthefollowingcontributoryfactorsplayeda role in the error: communication breakdowns, supervisionproblems,handoffproblems,failurestoestablishclearlinesof responsibility,andconflictamongclinicalstaff.Definingteam-work according to such behaviors is consistent with previousconceptualizations of teamwork in medicine
25
and the WorldHealth Organization’s definition of the term.
26
For problems of technical competence or knowledge, weidentified the task being performed by the physician when theerroroccurred.Thetaskoptionsweredrawnfromalistofcat-egories of general practitioner tasks provided by the Occupa-tionalInformationNetwork,
27
whicharegeneralenoughtoad-equatelycapturetheworkofcliniciansinarangeofspecialties. We made several modifications to the Occupational Informa-tionNetworklist.Specifically,wesplit1ofthecategories(“spe-cialized medical care to treat or prevent illness, disease, or in- jury”)intononproceduralandproceduralwork,andthenfurtherdivided the latter into procedures that were related to obstet-rical deliveries and those that were not.
RESULTS
Of 889 cases (claims with both error and injury) iden-tified in the parent study, 240 (27%) involved traineeswhose role in the error was judged to be at least moder-ately important. The claims were closed between 1984
(REPRINTED) ARCH INTERN MED/VOL 167 (NO. 19), OCT 22, 2007 WWW.ARCHINTERNMED.COM
©2007 American Medical Association. All rights reserved.
 on April 13, 2010www.archinternmed.comDownloaded from 
 
and2004andtheerrorsoccurredbetween1979and2001;72% of the claims were closed in 1990 or later.
SAMPLE CHARACTERISTICS
Table1
givesthecharacteristicsoftrainees,patients,andadverse outcomes in the study sample. The mean age of injuredpatientswas30years,and51%werefemale.Resi-dentswereinvolvedin87%ofthecases.Theadverseout-comesweregenerallysevere:one-thirdresultedinsignifi-cantphysicalinjury,one-fifthinmajorphysicalinjury,andan additional third in death. Nearly a third (30%) of thecases occurred in the outpatient setting.One-third of the cases involved trainees in obstetricsandgynecology(
Table2
).Thenextmostprevalentspe-cialties were general surgery, adult primary care, ortho-pedicsurgery,andpediatrics.Collectively,78%ofthecasesinvolved trainees from 1 or more of these 5 specialties.Characteristics of the parent study sample have beenreportedelsewhere.
12
The240traineeerrorsdifferedfromtheir 649 nontrainee counterparts on several measures.Alargerproportionoftraineeerrorsoccurredduringin-patient care (70% vs 52% [
P
.001]). Patients injuredin trainee errors were younger on average (30 years vs38 years [
P
.001]) and more likely to sustain fatal in- jury (33% vs 24% [
P
=.008]). In addition, a larger pro-portionoftraineeerrorsinvolvedobstetricsevents(30%vs21%[
P
=.003])andfewerinvolvedmissedordelayeddiagnosis (21% vs 32% [
P
=.002]).
CONTRIBUTING FACTORS
Cognitive factors contributed to nearly all of the traineeerrors,with72%ofcasesinvolvingjudgmenterrorsand57%involvingfailuresofvigilanceormemory(
Table3
).Fifty-eight percent of the cases involved lack of techni-cal competence or knowledge and 70% involved team-work-related factors. The most prevalent types of team-work factors were lack of supervision and handoffs.Eightcontributingfactorsweresignificantlymorepreva-lentamongtraineecasesthannontraineecases(Table3).Lack of technical competence (58% vs 42% [
P
.001]),lackofsupervision(54%vs7%[
P
.001]),handoffprob-lems(19%vs13%[
P
=.02]),andexcessiveworkload(19%vs 5% [
P
.001]) were particularly noteworthy contrib-uting factors in the comparison, both because the differ-ences were large and because these contributing factorswereprevalentwithinthetraineegroup.Attheaggregatelevel, teamwork factors contributed to 70% of trainee er-rors,morethantwicethefrequencywithwhichtheycon-tributed to errors (
P
.001).The trainee errors involved a mean of 3.9 contribut-ing factors, compared with a mean of 2.7 factors among
Table 1. Characteristics of Trainees, Patients,and Adverse Outcomes in 240 Trainee Errors
Characteristic No. (%)
a
TraineesResidents 208 (87)Interns 31 (13)Fellows 30 (13)PatientsFemale 121 (51)Age, mean, y 30
1 61 (25)1-17 23 (10)18-34 54 (23)35-49 52 (22)50-64 30 (12)
64 20 (8)Health insurance
b
Private 46 (36)Medicaid 32 (25)Uninsured 31 (24)Medicare 11 (9)Other 8 (6)Adverse outcomesTypeBreach of informed consent 1 (
1)Psychological or emotional 3 (1)Minor physical 29 (12)Significant physical 79 (33)Major physical 48 (20)Death 80 (33)LocationInpatient 168 (70)Outpatient 72 (30)Clinical areaOperative 77 (32)Obstetrics 73 (30)Missed or delayed diagnosis 51 (21)Medication 39 (16)
a
Percentages do not sum to 100% because multiple providers wereinvolved in some errors.
b
Patient’s health insurance was missing in 112 claims (46%). Percentageswere calculated using nonmissing observations as the denominator.
Table 2. Specialty of Trainees Involved in Errors
SpecialtyCases,No. (%)
a
Obstetrics-gynecology 80 (33)General surgery 45 (19)Adult primary care 28 (12)Orthopedic surgery 19 (8)Pediatrics 14 (6)Anesthesiology 13 (5)Emergency medicine 11 (5)Neurosurgery 9 (4)Plastic surgery 6 (3)Radiology 5 (2)Urology 5 (2)Medical student 4 (2)Cardiology 3 (1)Hematology or oncology 3 (1)Neurology 3 (1)Cardiothoracic surgery 3 (1)Ophthalmology 3 (1)Infectious disease 2 (1)Physical medicine or rehabilitation 2 (1)Ear, nose, and throat 2 (1)Vascular surgery 2 (1)Psychiatry 1 (
1)
a
Percentages do not sum to 100% because multiple providers wereinvolved in some errors.
(REPRINTED) ARCH INTERN MED/VOL 167 (NO. 19), OCT 22, 2007 WWW.ARCHINTERNMED.COM
©2007 American Medical Association. All rights reserved.
 on April 13, 2010www.archinternmed.comDownloaded from 

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Thank you for posting this study. It is a rare glimpse into accurate statistics and facts surrounding medical malpractice cases.
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