Robin Diamond, senior vice president of patient safety and risk management, The Doctors Company

Physicians are always seeking ways to enhance patient safety. Taking a close look at research into real-life malpractice claims and incorporating some of the findings into their practices is one way physicians are reducing risks of adverse events. Studies provided by The Doctors Company provide insight into thousands of closed claims and shine a light on preventive actions. The following are examples of doctors who learned from these malpractice closed claims studies and, as a result, took patient safety in their practices and hospitals to the next level.

Cardiology

• Doctor spotlight: Sandeep S. Mangalmurti, MD, JD, cardiologist at the Bassett Healthcare Network in Cooperstown, New York.
• Risk trend: The Cardiology Closed Claims Study outlines liability pitfalls of improper medication management. Cardiovascular medications have inherent risks even when used correctly.
• Solution: This risk led Dr. Mangalmurti to change his daily practice when managing certain high-risk medications such as anticoagulants. "Coumadin, in particular, is associated with high-liability risk because of the risk of bleeding and its narrow therapeutic window," said Dr. Mangalmurti. To avoid medication mishaps or breakdowns in communication, he makes a point to be very clear about whether the general practitioner or cardiologist will manage the anticoagulant medication.

Emergency Medicine

• Doctor spotlight: Roneet Lev, MD, FACEP, chief of the emergency medicine department at Scripps Mercy Hospital in San Diego, California.
• Risk trend: The Emergency Medicine Closed Claims Study identified the need for rapid recognition of stroke patients and treatment for tissue plasminogen activator (tPA).
• Solution: Across the entire hospital system, Scripps Mercy Hospital now initiates its emergency protocol for potential strokes when the call is placed to 911. The patient is taken straight to the CT scan without stopping at an emergency department bed. This expedites patient care as they activate the stroke team.

Hospital Medicine

• Doctor spotlight: John D. Nelson, MD, internal medicine hospitalist at Overlake Medical Center in Bellevue, Washington.
• Risk trend: The Hospitalist Closed Claims Study reveals spinal epidural abscess—a disease relatively uncommon in the general population—is appearing in medical malpractice claims more frequently. A diagnosis-related error involving spinal epidural abscess can lead to dire consequences, including paralysis.
• Solution: "This study should serve as a strong reminder for hospitalists of the importance of maintaining a very high index of suspicion for spinal epidural abscess," said Dr. Nelson. Problems with back pain, leukocytosis, and fever are red flags, but Dr. Nelson states the literature isn't so simple. These symptoms alone do not equate with epidural abscess. It requires a great deal of judgment to decide which cases are deemed appropriate for this diagnosis. "If you think a patient could have it, and it's worth pursuing, you should pursue it now rather than later. So, for example, get an MRI tonight rather than tomorrow."

Internal Medicine

• Doctor spotlight: Howard Marcus, MD, internal medicine physician in Austin, Texas.
• Risk trend: The Internal Medicine Closed Claims Study found that 39 percent of claims resulted from a diagnosis-related allegation (failure, delay, or wrong).
• Solution: Dr. Marcus has conducted small group discussions with physicians in his multispecialty medical group of over 300 doctors to improve understanding of the underlying methodological reasons leading to cognitive error. "Diagnosis in medicine is often challenging. There are more than 8,000 diagnostic entities listed by the National Library of Medicine and every patient is unique. It is helpful to understand the effect that psychological biases such as 'overconfidence bias' or 'anchoring bias' may play in medical decision making," said Dr. Marcus.

Obstetrics

• Doctor spotlight: Marcus Tower, MD, obstetrician at the Cleveland Clinic's Hillcrest Hospital, Cleveland, Ohio.
• Risk trend: The most common patient allegation identified in the Obstetrics Closed Claims Study is delay in treatment of fetal distress—specifically, failure to act when presented with Category II or Category IIl fetal heart rate tracings.
• Solution: Upon learning of this trend, Hillcrest Hospital now offers physician and nurse classes, providing the opportunity to learn how to identify heart rate tracings in a wide spectrum of scenarios. "From [the classes] we had a standardization process. Everyone became a patient advocate. Everyone focused their attention on, for that moment, identifying something that could be ominous so that we could act in a very timely manner," said Dr. Tower.

Orthopedics

• Doctor spotlight: Ralph A. Gambardella, MD, orthopedic surgery and sports medicine specialist with the Kerlan-Jobe Orthopaedic Clinic in Los Angeles, California.
• Risk trend: The Orthopedics Closed Claims Study reveals patient factors contributed to injuries in 29 percent of claims. It found that patient nonadherence was more likely when there was inadequate communication between the patient or family members and the physician. The study also notes that determining whether a patient is an appropriate candidate for a procedure is an important part of providing good care.
• Solution: With communication being a prominent pitfall, the practice identified two areas where it could influence behavioral change:
  1. Incorporating a smartphone application to improve doctor-patient communication.
  2. Having the patient work directly with a financial advisor in-office and at the hospital to better understand financial responsibilities.
  The hospital also adopted a preoperative screening assessment to identify comorbidities, thereby improving the surgery selection process and lowering risk.

Plastic Surgery

• Doctor spotlight: Phillip Haeck, MD, a plastic surgeon at The Polyclinic in Seattle, Washington.
• Risk trend: The Plastic Surgery Closed Claims Study notes that 10 percent of claims against plastic surgeons involved miscommunication between the patient or family members and the doctor.
• Solution: Dr. Haeck presented the study to his six partners and 35 staff members where they reviewed communication practices. As a result, the practice administered changes to communication protocols among physicians, staff, and patients. It now has clear guidelines to identify each communication, when it took place, and what resulted. All communications—including social media exchanges between patient and staff—are now entered into the EHR to alert the surgeon of new communication.

By leveraging technology, implementing new protocols, and being better equipped to address scenarios that could negatively impact patient safety, these practices and hospitals are taking steps in advancing patient care. Further insights from doctors who are learning from malpractice claims are available in The Doctors Company's Innovations in Patient Safety video playlist.

Contributed by The Doctors Company (thedoctors.com)