June 2003 Bulletin

Professional Liability Committee continues study of medical errors

Jack C. Childers, Jr., MD
Chairman, Committee on Professional Liability

Snce the publication in 1999 of the Institute of Medicine’s report on medical errors, there has been increased interest in the subject, both as such and as part of the larger topic of patient safety. The Institute’s estimate that as many as 98,000 deaths annually may derive from medical errors has made it a "hot button" issue. This estimate is based on retrospective chart reviews by Brennan et al of patients hospitalized in New York in 19841 and by Thomas et al of patients hospitalized in Utah and Colorado in 1992.2

The AAOS Professional Liability Committee has conducted annual studies of actual malpractice claims for more than a decade. Beginning in 2000, it specifically focused on medical errors. These were conducted in a Western state (2000) and an Eastern seaboard state (2002). Another study had been scheduled for October of 2001, but was postponed in the wake of the atrocities of 9/11. All of the claims were against orthopaedists, but were otherwise unselected by the insurer to enable the Professional Liability Committee to independently assess whether each claim could be classified as a "medical error."

The committee’s first task was to define a "medical error." This proved surprisingly difficult. Authors writing on the subject sometimes refer to "failure of a planned action to be completed as intended, or use of the wrong plan" or to "the occurrence of a preventable adverse event."

These definitions do not necessarily imply that the error was the result of negligence (failure to adhere to an applicable standard of care). Example: A healthy young athlete with no history of circulatory difficulties undergoes uneventful arthroscopic meniscectomy but postoperatively incurs deep vein thrombosis and pulmonary embolus. This is a preventable adverse event. It resulted in harm to the patient and could have been avoided by anticoagulation. But, since the standard of care does not specify anticoagulation in such patients, it is not negligent and does not fall into the category of malpractice.

Furthermore, even if an error occurs, it may not result in harm to the patient. Example: A patient is ordered to have ASA 300 mg. but instead is given 600 mg, with no discernable ill effects. This clearly represents an error (the planned action was not completed as intended), but no adverse event, i.e., harm to the patient, took place.

For the sake of consistency, but with some reservations, the committee adopted these definitions, realizing that they inflate and reinforce the intuitive public assumption that all "medical errors" both result from negligence and harm the patient. As the above examples demonstrate, this is not the case.

Because of disparities in the databases (Table 1), the AAOS studies are not directly comparable with the previous studies of Brennan et al and Thomas et al.

Table 1

Brennan et al, Thomas et al

AAOS

Inclusion Criterion

Hospitalization

Filed Malpractice Claim

Location of Patient Base

New York, Utah, and Colorado

Western/Eastern Seaboard States

Method

Hosp. Chart Review

Insurance Co. Record Review

Dates of Patient Contact

1984 and 1992

Mid-late 1990’s

Place of alleged error

Hospital

All locales

Physician Specialty

All specialists

Orthopaedists

 

While the results from the studies of Brennan et al are not expected to be directly comparable with those of the AAOS, the differences (Table 2) are those which might be intuitively expected: the rates for performance errors, especially technical performance, were higher for the surgical patient population of the AAOS studies than the general medical patients of Brennan et al, while the reverse was true for prevention and medication errors. There was no significant difference in diagnostic and system categories.

Table 2

Comparison of Types of Medical Error, New York Study (Brennan et al) Compared to AAOS Study in Western state (2000) and Eastern seaboard state (2002).

Type of Error

% B&L

%AAOS (2000)

%AAOS (2002)

Performance*

44

72

52

Inadequate preparation

9

1

2

Technical

76

90

86

Inadequate monitoring

10

4

8

Inappropriate or outmoded therapy

3

1

6

Avoidable delay

7

2

0

Practice outside area of expertise

2

2

2

Other

14

0

0

Prevention*

25

9

2

Failure to take precautions to prevent accident

45

46

100

Failure to utilize indicated test

23

8

0

Failure to act on results of test

21

8

0

Use of inappropriate test

1

0

0

Avoidable delay

31

8

0

Practice outside area of expertise

4

0

100

Other

19

31

0

Diagnostic*

17

10

30

Failure to use indicated test

50

36

32

Failure to act on results of test

32

21

24

Use of inappropriate test

1

0

8

Avoidable delay

55

36

40

Practice outside area of expertise

6

7

0

Other

15

0

8

Medication*

10

2

1

Dosage or route

42

67

0

Failure to recognize possible interactions

8

0

0

Inadequate follow-up

45

0

0

Inappropriate drug

22

33

100

Avoidable delay

14

0

0

Practice outside area of expertise

5

0

0

Other

9

0

0

System*

4

7

15

Defective equipment

8

0

0

Needed equipment unavailable

5

10

0

Inadequate monitoring system

10

20

40

Inadequate reporting or communication

26

20

64

Inadequate training of personnel

31

0

0

Delay in provision or scheduling of service

14

0

8

Inadequate staffing

6

0

0

Inadequate functioning of hospital service

8

0

0

Other

20

50

0

Total

100

100

100

* The total of the categories for each study (bold) is 100%, but totals within categories may be greater than 100% due to multiple causes in a single case.

 

In the AAOS study, the overall error rate as well as the percentage of errors felt by the reviewer to be due to negligence was significantly higher (Table 3). This was due to the inclusion criterion for the AAOS study, which only reviewed records of patients who had filed a malpractice claim.

Table 3

Table 3 presents the combined results of the two AAOS studies, with selected comparisons from the study by Thomas et al:

AAOS

Thomas

Total charts Reviewed

675

Charts with a medical error

190
(28% of charts reviewed)

2.9%

Errors due to negligence

121
(64% of all errors)

32.6% UT all errors)
27.4% CO

Errors resulting in harm

144
(76% of all errors)

 

Table 4 presents the location of the alleged error (Eastern seaboard study only). These data may be obsolete, as the events took place in the mid 1990s. There are more surgicenters now, and the range of procedures they perform is broader.

Table 4

Eastern Seaboard State Cases

Number of cases

Office

13

O/P Surgicenter

1

Hospital

52

Unknown

9

 

Table 5 presents the dramatic effect of a medical error on indemnity paid to successful claimants.

Table 5

Western & Eastern Cases

Average indemnity paid

Cases with medical error

$196,500

Cases without medical error

$79,700

Finally, Table 6 lists some of the most common errors detected. Categories and subcategories are in approximate order of occurrence (some cases had more than one error, and some errors were determined not to be negligent, or did not result in harm).

Table 6

Western & Eastern Cases

1. Technical

A. Improper performance of surgery, esp. retroversion of acetabular prosthesis
B. Inadequate or inappropriate hardware or instruments
C. Inadequate training of surgical assistant

2. Failure to Timely Diagnose/Treat

A. Compartment syndrome
B. Postoperative infections and thromboses
C. Syndesmotic injury in ankle trauma
D. Missed lesion on X-rays ("read to the corners")

3. Wrong Site

A. Wrong Side
B. Wrong level of spine
C. Wrong finger or toe
D. Wrong patient

 

The Professional Liability Committee will continue focusing on medical errors in future closed-claim studies. It is anticipated that, just as with the diagnostic or procedure-based data resulting from earlier closed-claims studies, experience over time will enable us to draw more useful conclusions and practical lessons.

References:

  1. Brennan, TA, Leape, LL, Laird, NM, et al, NEJM 324(6), 370-376, 1991.
  2. Thomas, EJ, Studdert, DM, Burstine, HR, et al, Med Care (United States) 38(3), 261-271, 2000.

Jack C. Childers, Jr., MD, is chair of the AAOS Committee on Professional Liability. He also serves as editor of the Academy’s orthopaedic risk management newsletter, Orthopaedic Medical Legal Advisor.


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