Critical Access Hospitals

2 0 1 7 M A L P R A C T I C E C L A I M S D A T A & R I S K A N A L Y S I S Critical Access Hospitals Patient Safety & Risk Solutions 1

Introduction This publication contains an analysis of the aggregated data from MedPro Group s critical access hospital claims closed between 2006 and 2015. All claims included in this analysis occurred at a critical access hospital. This analysis is designed to provide MedPro insured doctors, healthcare professionals, hospitals, health systems, and associated risk management staff with detailed claims data to assist them in purposefully focusing their risk management and patient safety efforts. Data are based on claim counts, not on dollars paid (unless otherwise noted). The type of claims and the details associated with them should not be interpreted as an actuarial study or financial statement of dollars paid; however, the information may be referenced for issues of relativity. 2

Executive Summary: Three Allegations, Responsible Services, and Locations Drive Claims Volume In the 10-year period analyzed, diagnosis-related, surgical treatment, and medical treatment allegations accounted for nearly 70% of all critical access hospital claims. These adverse events were attributed most often to emergency department (ED) physicians, nurses, and surgeons. 1 in 4 adverse events were diagnosisrelated; more than half of those occurred in the ED. Nearly 1 in 4 adverse events were surgical-related, primarily involving the technical competency of the surgeon or postoperative nursing care. 1 in 5 adverse events involved medical treatment, primarily consisting of performance of nonsurgical procedures, the majority of which took place in the ED or in the patient s room. Clinical and Financial Severity Half of all events involved a serious patient injury or death, and these events are associated with more than 80% of the dollars in this analysis. The distribution of these high clinical severity events nearly mirrors the distribution of diagnostic, surgical, and medical treatment-related allegations. An exception to the high severity equals high dollars rule is a surgical allegation in which the surgeon is the responsible service. If the surgical practice is not owned by the hospital, the focus quickly becomes the surgeon, and the hospital is often released from the claim with minimal to no payment. Focus on Nursing Care Nursing staff were identified as the primary responsible service in almost one-fourth of a diverse spectrum of claims across all allegation categories. These allegations most often involved patient falls, medical procedures relating to IVs/venipuncture, and postoperative surgical care. Nursing care allegations also accounted for nearly half of the total dollars paid. Further, in an additional 20% of claims, nursing care notably contributed to the adverse event in which another service was the primary responsible service. Office-Based Claims Hospitals also see office-based claims as a result of practice acquisition or the addition of clinics. Office-based claims accounted for about 10% of the total in this analysis. As is typical, the breakdown of the claims showed diagnosisrelated, medication-related, and treatment-related as the top allegations. 60% of these office-based claims arose from a primary care setting. 3

Three Allegation Categories Represent Most Volume, Highest Clinical Severity, and Total Dollars Paid Over the 10-year period analyzed, diagnosis-related, surgical treatment, and medical treatment allegations accounted for nearly 70% of all critical access hospital claims, almost twothirds of total dollars paid for defense and indemnity costs, and half of high clinical severity cases. Allegations of missed, wrong, and delayed diagnoses arising from an ED encounter were most common, followed by the performance of surgical and nonsurgical medical procedures. Medication-related allegations included ordering and administration errors. Patient environment allegations included failure to prevent patient falls and hospital-acquired infections. Obstetrics (OB)-related treatment allegations included labor & delivery issues and fetal distress management. Note: Any totals not equal to 100% are the result of rounding. 8% 9% 6% 9% 20% CLAIMS VOLUME BY ALLEGATION CATEGORY 25% 23% Diagnosis-Related Surgical Treatment Medical Treatment Medication-Related Patient Environment OB-Related Treatment Other The other category included allegations for which no significant claims volume exists; examples included anesthesia-related allegations, patient rights violations, and equipment-related claims. 4

Percentage of Claims Volume High Clinical Severity Outcomes Are Present in All Allegations TOP ALLEGATION CATEGORIES BY CLINICAL SEVERITY 100% 90% 80% 70% 60% 56% 61% 39% 45% 27% 75% Although OB-related claims had the highest rate of clinically severe outcomes, they represented only 6% of all cases and slightly more than 10% of the total dollars paid. These cases were generally delivery related. 50% 40% 30% 20% 38% 35% 57% 45% 36% 36% High Medium Low 10% 0% 6% 3% 4% 9% 25% Diagnosis-Related Surgical Treatment Medical Treatment Medication-Related Patient Environment OB-Related Treatment Note: Any totals not equal to 100% are the result of rounding. 5

High Clinical Severity Claims Equal More Dollars Paid Almost half of all claims involved a clinically severe patient injury, including death and permanent disability. Examples: CLAIMS VOLUME BY CLINICAL SEVERITY Failure to diagnose cauda equina in a patient who presented to the ED with severe back pain; premature discharge resulted in subsequent emergency surgery and permanent nerve damage 12% 16% 4% Inadequate nursing management of postoperative 49% 81% surgical patient s pain and progressive deterioration led to untreatable sepsis resulting from perforated 40% colon and subsequent death High clinical severity claims also corresponded with financial severity. 81% of total dollars (expense + indemnity) were paid on high clinical severity claims. Claims Total Paid Note: Any totals not equal to 100% are the result of rounding. High Medium Low 6

Percentage of Respective Category Three Responsible Services Represent Most Claims, Dollars, and Clinically Severe Outcomes 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% The primary responsible service is the specialty assigned primary causation for the patient s injury (e.g., an emergency medicine physician for a missed diagnosis). Emergency medicine, nursing, and surgical specialties accounted for the majority of the claim volume, and nursing accounted for almost half of total dollars paid. Claims Volume Total Dollars Paid High Clinical Severity Emergency Nursing Surgeons Primary Care Radiology Medicine Anesthesiology Obstetrical Other Specialties Note: Any totals not equal to 100% are the result of rounding. 7

Connecting Allegation Details to Responsible Services The most frequently occurring allegation details are noted below with their attribution to the most frequently noted responsible service(s). ALLEGATION CATEGORY DESCRIPTION TOP RESPONSIBLE SERVICE Diagnosis-Related Allegations of missed, wrong, and delayed diagnoses: diagnoses were varied and included cardiac conditions, fractures, malignancies, and infections; more than half of all diagnosis-related claims arose from an ED encounter Emergency Medicine Surgical Treatment Performance of surgery: total joint replacement orthopaedic surgeries and abdominal surgeries were most common Postoperative management of the surgical patient: failure to recognize and report worsening postoperative clinical conditions, including pressure injuries Orthopaedics General Surgery Nursing Medical Treatment Management of course of treatment: included management of diseases such as respiratory distress and hemorrhagic shock Performance of nonsurgical procedures: included epidural injections resulting in nerve injuries and traumatic intubations Emergency Medicine Medication-Related Management of medication regimens: primarily arose from care given at clinic/physician office, and most notably involved narcotic regimens; patient noncompliance with medication regimens was frequently noted as a contributing factor Family Medicine OB-Related Delay in treatment of fetal distress and performance of vaginal deliveries: included failure to recognize and report nonreassuring fetal heart monitoring strips OB Family Medicine 8

Focus on Nursing Staff Primary Role Allegations in which nursing staff were noted as the primary responsible service were varied and the most costly. They most often involved delayed responses to postoperative changes, nerve damage resulting from improper IV insertion technique, and failure to prevent patient falls. Other nursing allegations included: Failure to prevent patient elopement Wrong medicine/wrong dose administration Failure to mitigate the risk of pressure injuries Non-Primary Role Nursing staff was also a responsible service in a contributing role to an additional 20% of critical access hospital claims, most often within the surgical and diagnosis-related allegations, which underscores the importance of a cohesive healthcare team. Common scenarios included: Delayed recognition/communication of postoperative changes Failure to ensure use of correctly sized prosthetic devices Failure to use chain of command to pursue additional diagnostic testing Failure to reassess the patient prior to discharge Mismanagement of respiratory distress and skin integrity Failure to clarify medication orders before administration Delayed response to fetal distress 9

Three Locations Represent Most Claims, Dollars, and Clinical Severity 39% 33% Combined, outpatient settings (including hospital-owned/affiliated clinics, physician offices, ambulatory surgery centers, imaging centers, and endoscopy centers) and the ED were most frequently the site of critical access hospital claims. Claims arising in the ED, and inpatient claims arising from nursing-related events in patient rooms accounted for the highest percentage of total dollars paid, whereas claims arising from the ED were the most clinically severe. 28% Outpatient Emergency Inpatient Note: Any totals not equal to 100% are the result of rounding. 10

Percentage of Respective Category Three Locations Represent Most Claims, Dollars, and Clinical Severity Claims Volume Total Dollars Paid High Clinical Severity LOCATIONS 40% 35% 30% 25% 20% 15% 10% 5% 0% Emergency Surgery-Related Patient Rooms Clinic/Physician (IP and OP) Office L&D Radiology Special Procedures Other Note: Any totals not equal to 100% are the result of rounding. IP: inpatient; L&D: labor & delivery; OP: outpatient 11

Key Risk Factors in High Clinical Severity Claims Risk factors are broad areas of concern that may have contributed to allegations, injuries, and the initiation of claims. The following pages illustrate details about these risk factors, including technical competency, clinical judgment, communication, administrative, and documentation, that contribute to high clinical severity events with a focus on the top three responsible services: emergency, nursing, and surgeons. Risk factors are composed of more narrowly defined processes involving delivery of safe patient care. These details, along with their attribution to the responsible service most often associated with the factors in high clinical severity events, are noted on the following pages. Cases are used to illustrate the care breakdowns. Following the details on risk factors are important risk mitigation strategies related to them. Focused risk strategies are also provided for the top three responsible services. 12

Frequency of risk factors All Claims Volume Key Risk Factors in High Clinical Severity Claims TOP RISK FACTORS: HIGH CLINICAL SEVERITY CLAIMS Nursing Surgeons Emergency 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Clinical Judgment Technical Competency Communication Administrative Documentation Interpreting the information above: High clinical severity claims attributed to nursing staff as the responsible service involved clinical judgment issues in 91% of the cases (and so forth); additional breakout noted on the following pages. Technical Competency: involves surgical and procedural technical skill. Totals do not equal 100% because more than one factor is associated with each claim. 13

Key Process of Care Breakdowns and Responsible Services Case: On postoperative day one after a Nissen fundoplication, patient was started on a patient-controlled analgesia pump for a pain level of 5/10. As the day progressed, symptoms worsened, but nursing staff members did not adequately monitor the changes, nor did they fully assess the patient to determine possible reasons for the deterioration. Ultimately, a bowel perforation was discovered during emergency surgery, but postoperatively the patient died from sepsis. 80% 70% 60% 50% CLINICAL JUDGMENT Case: Patient presented with gastrointestinal (GI) bleed; emergency physician did not order either a GI or surgical consult. He was admitted and although a critically low hemoglobin was noted by the hospitalist, consult/referral was delayed for several hours. Patient developed hemorrhagic shock from duodenal bleed, and died during emergency surgery. During subsequent litigation, an expert contended that surgery was indicated upon presentation to the ED. 40% 30% 20% 10% 0% Patient Assessment Issues Patient Monitoring Failure/Delay in Obtaining Consult/ Referral Note: All graphs represent the frequency of each factor in high clinical severity claims volume for each specialty (e.g., 70% of high severity claims involving nursing care reflect a clinical judgment/patient monitoring issue). Values lower than 20% are not displayed. Totals do not equal 100% because more than one factor is associated with each claim. Emergency Nursing 14

Key Process of Care Breakdowns and Responsible Services Case: Patient with a history of using the ED as a source of primary care for her poorly controlled diabetes presented with shortness of breath, severe upper abdomen/chest pain, nausea, and vomiting. She was diagnosed with hyperglycemia and a urinary tract infection and was discharged to home. She returned 12 hours later with worsening symptoms and was taken to the OR. However, she was septic and subsequently died. Plaintiff s expert contended that the emergency physician and nursing staff did not communicate clearly with each other about the patient s condition and that the nursing staff should have exercised the chain of command to advocate for admission of the patient during the first visit. Case: Patient presented for a laparoscopic hysterectomy. Per the patient s husband, the surgeon did not review any risks of the procedure, and stated only that laparoscopic procedures were less invasive. Laceration to the common iliac artery occurred during surgery and was repaired; blood transfusions and additional anesthesia support were necessary. Postoperatively, the patient developed respiratory distress and was unable to be resuscitated. Note: All graphs represent the frequency of each factor in high clinical severity claims volume for each specialty. Values lower than 20% are not displayed. Totals do not equal 100% because more than one factor is associated with each claim. 80% 70% 60% 50% 40% 30% 20% 10% 0% COMMUNICATION Top issues: reporting of critical test results in a timely manner and keeping the lines of communication open between nursing staff and physicians Communication Among Providers Communication Between Patient/Family and Providers Emergency Nursing Surgeons Top issue: inadequate informed consent 15

Key Process of Care Breakdowns and Responsible Services Case: Paraplegic patient presented for surgical repair of torn rotator cuff. Postoperative nursing skin assessment noted that the patient was at a high risk for skin breakdown. One initial nursing note reflected repositioning of patient, but frequency of repositioning and ongoing skin assessments were not documented as required by policy. Three days postop, patient had developed a Stage II sacral ulcer. Nursing documentation improved after the ulcer developed. The patient was discharged to home, but the wound ultimately progressed to a Stage IV and the patient was readmitted for significant ongoing care. Top issues: noncompliance with patient monitoring policies, OR-specific count and equipment usage policies and diagnostic test tracking and reporting procedures 80% 70% 60% 50% 40% 30% 20% 10% 0% ADMINISTRATIVE Policy/Protocol Not Followed Emergency Nursing Surgeons Note: All graphs represent the frequency of each factor in high clinical severity claims volume for each specialty. Values lower than 20% are not displayed. Totals do not equal 100% because more than one factor is associated with each claim. 16

Key Process of Care Breakdowns and Responsible Services Case: A child presented to the ED with nausea, vomiting, and fever after hitting his head 3 days previously. An entire set of vital signs was documented upon admission. He was discharged to home with a viral 40% DOCUMENTATION syndrome diagnosis, orders for acetaminophen and ibuprofen, and instructions to follow up with primary care and to return to the ED if symptoms persisted. The next morning, the child presented to a 35% 30% different ED with physical signs of meningitis, which was confirmed by a lumbar puncture. He sustained an almost total hearing loss requiring 25% cochlear implants. ED charting did not include documentation of differential diagnoses, including meningitis, nor was a timeline of symptom progression or full physical assessment noted. A second set 20% 15% of vitals was not recorded prior to discharge. 10% Top issues: insufficient documentation of physician diagnostic thought process and operative reports; nursing documentation content inconsistent with that of physician 5% 0% Insufficient Documentation Content Emergency Nursing Surgeons Note: All graphs represent the frequency of each factor in high clinical severity claims volume for each specialty. Values lower than 20% are not displayed. Totals do not equal 100% because more than one factor is associated with each claim. 17

Key Risk Factors Summary Inadequate clinical assessment, including failure to correlate patient complaints and/or test results with additional diagnostic testing or specialty consultations, in the ED Technical competency of surgeons Breakdown in communication among members of the patient s care team, and inadequate informed consent discussions with surgical patients Failure to follow hospital nursing policies and procedures, including those addressing chart documentation, medication reconciliation, and patient monitoring Insufficient documentation of clinical findings across the top three responsible services 18

Important Risk Mitigation Strategies Clinical Judgment Complete a thorough patient assessment that: averts biases that could lead to a narrow diagnostic focus; and ensures appropriate consultations and testing will be ordered in timely manner. Reconcile inconsistent findings and test results with the initial impression. Ensure tests and consultations ordered are completed, and results are reported to patients. Use evidence-based guidelines for myocardial infarctions, cerebrovascular accidents, intracranial bleeds, etc. Consider clinical decision support aids and group decision-making to support clinical reasoning. 19

Important Risk Mitigation Strategies Technical Competency To minimize the risk of recognized complications and to ensure adherence to credentialing policies, evaluate surgical skills and competency with surgical equipment. Communication Ensure prompt communication and documentation of relevant findings from consultations and referrals. Thoroughly review the health record at each patient encounter to stay informed of the most recent clinical information. Conduct a thorough informed consent discussion with the patient, using layman s language and avoiding medical jargon, and document the discussion in the health record. Focus on patient education related to medication regimens and discharge instructions. Create a patient-centered environment in which patients are empowered to ask questions. 20

Important Risk Mitigation Strategies Administrative Comply with processes for following up on radiology discrepancies and communicating test results received after discharge. Ensure adherence to policies for fall prevention, pressure wound prevention, postoperative monitoring, and medication reconciliation. Be aware of and comply with supervisory requirements for medical residents, advanced practice providers, and scribes. Documentation Verify that documentation supports clinical rationale, diagnosis, treatment decisions, and surgical findings. Ensure any discrepancies between the documentation of all providers is explained. Provide thorough and timely documentation of each patient s condition at discharge. 21

Focused Risk Strategies for Emergency Ensure appropriate evaluation, reevaluation, and use of symptom-based protocols. Document a thorough history and physical exam of patient symptoms. Reconsider differential diagnoses of returning patients, patients who show no signs of improvement, and patients who are intoxicated or seeking drugs. Describe rationale for inclusion/exclusion of differential diagnoses. Document and explain any inconsistency in the notes of the emergency physician and other providers, including triage nurses. Seek diagnostic input from appropriate specialties, be persistent if necessary, and document the pertinent details of any discussions. Prior to discharge, reevaluate patients who have had abnormal vital signs/test results and document the repeat vital signs. Make a thorough notation of each patient s condition at discharge, including symptoms and changes in condition. Ensure post discharge follow-up by focusing on radiology discrepancies, results received after discharge, and the patient call-back process. 22

Focused Risk Strategies for Nursing Reinforce the importance of a thorough patient evaluation and assessment. Conduct continuing education focused on the recognition of early warning signs of patient decompensation, and create an environment in which any staff member can escalate concerns through the chain of command. Stress the importance of listening to, documenting, and when appropriate, acting upon patient/family concerns. Ensure understanding of and compliance with postoperative orders, and emphasize the importance of communicating changing/worsening clinical symptoms to the surgeon/attending physician. Emphasize the importance of timely and thorough documentation; stress the impact that accurate and consistent documentation has on formulating a care plan. 23

Focused Risk Strategies for Surgeons Recognize that a cohesive and respectful OR team is crucial to ensuring a safe surgical environment and good patient outcomes. Focus staff education on mitigation of high risk situations, including surgical fires, wrong side/site surgery, medication errors, equipment availability, surgical counts, and response to rapid patient decompensation. Emphasize the importance of a standardized informed consent process, one in which the patient has ample opportunity to ask questions and is educated on the phases of the surgical process (including preoperative and postoperative). Reinforce the importance of selecting the most appropriate environment for the patient s surgery (inpatient OR/ambulatory surgery setting) and consider all surgical risks specific to the patient. 24

A Note About MedPro Group Data MedPro Group has entered into a partnership with CRICO Strategies, a division of the Risk Management Foundation of the Harvard Medical Institutions. Using CRICO s sophisticated coding taxonomy to code claims data, MedPro Group is better able to identify clinical areas of risk vulnerability. All data in this report represent a snapshot of MedPro Group s experience with critical access hospital claims, including an analysis of risk factors that drive these claims. Disclaimer This document should not be construed as medical or legal advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions. MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and regulatory approval and may differ between companies. 2017 MedPro Group Inc. All rights reserved. 25