What drives risk in the clinic setting? To answer this crucial question, Constellation examined data drawn from years of medical professional liability (MPL) insurance claims from its member clinics. Four top drivers of risk in clinics rose to the top: the diagnostic process, medical treatment, medication administration and surgical procedures. Clinic risks aren’t always based on the level of clinical knowledge or the technique of clinicians; for example, many adverse events occur because of breakdowns in diagnostic tracking and follow-up systems. As a subset of all health care settings, including hospital and ambulatory care settings, clinics tend to have fewer staff and are likely to have fewer RNs with the clinical experience required for telephone triage, or the expertise and systems training needed to aid in assessment and monitoring after procedures.
Clinics also often have less advanced resuscitative training and equipment to deal with emergencies that may occur. And clinics often lack risk and patient safety staff and programs, which can limit progress toward better procedures and systems to mitigate risk.
Staying abreast of the key risk factors identified by the data enables clinics to make the changes needed to mitigate those risks, fill gaps in expertise and improve processes. Decision support tools, for example, can help clinicians limit diagnostic error, and better systems can aid clinicians in monitoring test results and coordinating follow-up care. Clinics may also determine a need for more training for care teams or more education for patients. These are all worthwhile efforts to support clinicians, limit liability and improve care for patients.
In the Clinic
Medical treatment errors are
#1 in OCCURENCE
Diagnostic errors are
#1 in COST
Diagnostic (Dx) error claims are the most expensive claims for clinics, contributing to almost half of costs (42%). This is largely due to the severity of harm caused by missed or delayed diagnosis. Medical treatment allegations are the second-most expensive (24%), even though they represent the largest percentage of all clinic claims (34%).
Top Allegations in Clinic Setting
Nearly one-third of costs are driven by claims against family medicine physician care teams. They also account for the largest percentage (18%) of clinic claims.
Top Responsible Care Teams in Clinic Claims
More than half of clinic claims are of medium severity, and about one-quarter are of high severity. Medium-severity claims can include temporary or permanent injury such as infections, missed fractures or retained surgical objects. High-severity claims include major or grave permanent injury such as blindness, paralysis, quadriplegia or death.
Severity of Harm in Clinic Claims
Top Risk Driver in Clinics—Diagnostic error allegations
In the clinic setting, Dx errors are the most expensive allegation, accounting for 42% of costs and 26% of claims. In general, Dx errors are more likely to originate in the clinic setting than in a hospital, because the clinic is most often where patients arrive with initial symptoms or for routine checkups. If testing is needed, the clinic may need to refer the patient to another facility or specialist to have those tests performed. Such referrals require follow-up and coordination of care, as well as appropriate timing and patient compliance. The complexity involved, and the multiple steps needed, can lead to gaps in care that drive Dx errors.
In the Clinic
Diagnostic Errors are
#1 in COSTS
#2 in OCCURRENCE
Over half (69%) of clinic Dx error claims begin with issues that arise during the initial patient assessment: assessing and evaluating symptoms, establishing a differential diagnosis list, and ordering diagnostic tests to rule in or out potential diagnoses.
In many clinic cases (23%), tests and results
processing is also an issue. Tests may be mislabeled or mishandled, findings may be inaccurate, or the ordering physician may fail to review the results in a timely manner, to name just a few possibilities.
Problems with follow-up and coordination occur in almost half of these claims (52%). Because follow-up care and care coordination are primarily delegated to other members of the care team, an accurate and timely diagnosis depends as much on the team and the clinic’s systems as it does on the diagnosticians themselves. Establishing formal communication, improving processes and helping patients stay engaged can help improve the diagnostic process and limit errors.
Dx Error Top Contributing Factors
Case Example: Diagnostic Error
Failure to diagnose coronary artery disease leads to heart attack and death of a 39-year-old man.
A 39-year-old man with a history of diabetes, hypertension, smoking and pericarditis was examined by his family physician (FP) for chest discomfort and left shoulder pain. The FP noted the physical examination was normal, with a normal cardiac rate and rhythm, as well as full range of motion with some pain in the left shoulder. The FP’s assessment included uncontrolled hypertension and pain in the joint of the left shoulder. The FP did not order any testing, but renewed the man’s blood pressure medication prescription and made a referral for a cardiology appointment for chest and left shoulder discomfort, and history of pericarditis. Two days later, the man had a sudden onset of chest pain and went to the emergency department (ED) of his local hospital. The ED physician placed him on a cardiac monitor that showed ventricular tachycardia. The man became unresponsive, and cardiac resuscitation was initiated. Despite resuscitation efforts, the man died. The cause of death was acute myocardial infarction secondary to coronary artery disease. The family filed a malpractice claim alleging failure to timely diagnose coronary artery disease causing death. The experts who reviewed the care felt this man had multiple elevated risk factors for coronary artery disease, and that the FP should have done an EKG and included coronary artery disease in the differential diagnosis to rule out a potentially serious condition.
These contributing factors played a role in the allegation of failure to diagnose and are amenable to risk management strategies:
Initial diagnostic assessment: Patient assessment failure in evaluating history and symptoms. This patient’s history should have been a red flag to establish a robust differential diagnosis list and rule out coronary artery disease.
Initial diagnostic assessment: Narrow diagnostic focus and lack of differential diagnosis list
Initial diagnostic assessment: Failure to order diagnostic tests to rule out a potentially serious cardiac condition
Top Risk Driver in Clinics—Medical treatment allegations
In the clinic setting, medical treatment allegations account for 34% of claims and 24% of costs. The majority of these claims fall into two categories—improper performance of a procedure (43%) and improper management of a medical treatment (43%). These claims usually involve routine, common procedures such as injections, venipunctures, spinal taps and biopsies.
In the Clinic
Medical Treatment Allegations are
#1 in OCCURENCE
#2 in COST
Just over half (52%) of medical treatment claims involve technical skill problems during the performance of the procedure as a contributing factor. Often, there are problems with skill combined with clinical judgment issues, communication breakdowns with the patient, or patient behavior-related issues such as noncompliance with the treatment plan.
Medical Treatment
Top Contributing Factors
Case Example: Medical Treatment
Improper resuscitation following improper performance of an occipital nerve block leads to a woman’s death.
A neurologist treated a 42-year-old woman in his clinic for over two years with occipital nerve blocks for chronic headaches due to a past motor vehicle accident. During a treatment, the patient lost consciousness and the neurologist could not feel her pulse. He began CPR, and his nurse called 911. EMS arrived within 15 minutes and detected a pulse. They transported the woman to the local ED. On the way, she suffered another cardiac arrest. She died four days later after brain death was confirmed and life support was withdrawn. Her family filed a malpractice claim against the neurologist alleging improper performance of a medical procedure and improper management of her resuscitation. The experts who reviewed the neurologist’s care were critical of the resuscitation efforts because no IV was started and no epinephrine was given. They felt the cardiac arrest was caused by the inadvertent injection of the bupivacaine intravascularly.
These contributing factors played a role in the allegations of improper performance of the procedure and improper management of medical treatment and are amenable to risk management strategies:
Clinical judgment: Improper selection of treatment during resuscitation
Technical skill and performance: Inadvertent intravascular injection of bupivacaine during occipital nerve block
Top Risk Driver in Clinics—Medication allegations
Medication allegations represent 12% of claims and 18% of costs in the clinic setting. Medication errors can occur during any stage of the medication process—ordering, dispensing, administering and monitoring. The majority of medication allegations (47%) concern improper medication regimen management. These claims involve adverse effects and drug interactions of prescribed medications that should have been managed by monitoring medication effects and lab values. An ordering error was involved in 18% of these claims, including giving a wrong dose or wrong medication. Administration errors, such as injections at the wrong site or medication administered by the wrong method, were involved in 11% of cases.
In the Clinic
Medical Errors are
#3 in COSTS
#4 in OCCURRENCE
The leading factors contributing to medication error claims include clinical judgment issues with the selection or management of a medication (53%) and with patient assessment (33%), as well as monitoring issues (27%). Communication breakdowns were also frequent, both with the patient (37%) and among the care team (23%)
Medical Treatment
Top Contributing Factors
Case Example: Medical Error
A woman dies from a hemorrhage after clinicians fail to monitor her anticoagulant levels.
A 73-year-old woman was examined by a nurse practitioner (NP) at the patient’s usual primary care clinic for complaints of intermittent dull low back pain. The woman had been on anticoagulant therapy for a number of years because of a history of congestive heart failure, mitral valve stenosis and atrial fibrillation. The NP prescribed an antibiotic for a presumed urinary tract infection and advised the woman have her INR (international normalized ratio) labs done in two days to monitor her anticoagulant therapy. At that visit, the woman’s INR level was high, and she complained of blood in her urine. A family physician (FP) administered vitamin K to counteract the high INR level and prescribed a second dose for that evening at home. He also discontinued her anticoagulant but continued the antibiotic. The next morning, the woman’s INR value remained high, and the FP advised her to go to her local ED the next morning to have labs rechecked because the clinic was closed on weekends. Later that afternoon, the woman presented to the ED with complaints of dizziness and blurred vision. The ED clinician diagnosed an intracranial hemorrhage and admitted her to the hospital. As a result of the hemorrhage, the woman suffered vision impairment, balance difficulties, mental confusion and difficulty with both oral and written communication. She filed a malpractice claim against the clinic and its clinicians for improper medication regimen management. The experts who reviewed the care were critical of the NP for the antibiotic choice (contraindicated with the woman’s anticoagulant) and for not decreasing the anticoagulant dose when prescribing the antibiotic. They were critical of the FP for failing to timely treat the elevated INR levels with hospitalization.
These contributing factors played a role in the allegation of medication error and are amenable to risk management strategies:
Selection/management of medication: Failure in the selection of medication due to contraindications with the anticoagulant
Patient monitoring: Failure to order INR levels at the time of prescribing
Selection/management of medication: Anticoagulant dose was not decreased when prescribing the antibiotic
Patient monitoring: Failure to recognize/ appreciate severe symptoms and elevated INR test results
Patient monitoring: Failure to recognize/ appreciate severe symptoms and elevated INR test results
Top Risk Driver in Clinics—Surgical allegations
Surgical allegations represent 14% of clinic claims and 10% of costs. These claims mostly involve orthopedists and specialty surgeons, and primarily include allegations of improper surgical patient management. Improper surgical patient management allegations comprise the pre-, intra-, and postoperative phases of surgical care.
In the Clinic
Surgical Allegations are
#3 in OCCURRENCE
#4 in COSTS
Nearly half (47%) of surgical claims originate from allegations of improper care by orthopedic physicians and their care teams. General surgery care teams were second in cost incurred, but the incidence of those claims was roughly half that of orthopedic claims. Injuries resulting from improper surgical patient management include infection, pain, malunion/nonunion, and nerve and organ damage.
Top Responsible Clinicians and Care Teams Surgical Clinic Claims
More than two-thirds (68%) of surgical clinic claims involved errors in technical skill and performance, including known risks of the surgical procedure. Combined with the communication breakdowns, this represents an opportunity to improve the informed consent process in the clinic prior to the surgical procedure.
Surgical Top Contributing Factors
Case Example: Surgical Allegations
Poor assessments and communication breakdowns postoperatively lead to permanent nerve damage in a 60-year-old man.
An orthopedic surgeon performed a right total knee arthroplasty on a 60-year-old man with a history of knee pain and osteoarthritis. Six days later on a Friday afternoon, the man called the orthopedist’s office complaining of pain and swelling in his right knee and calf. The office team member did not communicate with the orthopedist but told the man to keep his orthopedic appointment the following week and to follow the postoperative instructions to use ice and elevation for swelling. The next week, the orthopedist examined the man, who was still complaining of right lower leg pain, swelling and weakness. The orthopedist ordered a duplex exam, which showed no evidence of a deep vein thrombosis. Over the next several weeks, the man continued to complain of pain, swelling and weakness in his right lower leg, for which he called the orthopedist’s office several times. Six weeks after surgery, the man went to his local hospital ED with complaints of right lower leg pain, swelling and weakness. The ED physician ordered a Doppler ultrasound of the right knee, which showed a pseudoaneurysm of the popliteal artery. A vascular surgeon was consulted, and he performed a repair of the pseudoaneurysm. The man suffered a permanent nerve injury and foot drop. He was unable to return to work and later filed a malpractice claim against the orthopedist alleging improper performance of surgery and failure to obtain informed consent. The experts who reviewed the care felt that the popliteal artery was injured during surgery, causing the man to develop the pseudoaneurysm, which put pressure on the peroneal nerve, leading to the nerve injury and foot drop. The experts were critical of the delay in diagnosing the pseudoaneurysm, considering the man made repeated complaints of pain, swelling and lower leg weakness. The experts were also critical of the orthopedist’s office team in the handling of the man’s repeated telephone calls complaining of continued symptoms. The involved orthopedic office team members testified that they did not have formal telephone triage protocols to manage postoperative patients.
These contributing factors played a role in the allegations of improper surgical patient management and improper performance of a procedure and are amenable to risk management strategies:
Patient assessment issues: Lack of adequate assessment and failure to recognize signs and symptoms of a known procedural risk
Communication breakdowns among the team with the failure to consult the surgeon.
Patient assessment issues: Failure to recognize signs and symptoms of a procedural complication and overreliance on negative test result
Patient assessment issues: Narrow diagnostic focus leading to failure to establish a differential diagnosis list
Patient assessment issues: Failure to respond to repeated complaints and symptoms
Patient assessment issues: Failure of care team to appropriately triage and respond to postoperative complaints
In the Clinic:
Risk Management Tips
✓ Provide clinical decision support tools to help your clinicians and care teams:
– Consider and rule out potentially serious diagnoses.
– Assess a patient’s risk for surgery, procedure or medications.
– Select appropriate treatment for commonly seen conditions.
– Triage a patient’s symptom-related complaints to rule out potentially serious conditions.
✓ Assess your follow-up and test management systems to find gaps in follow-up care and in monitoring diagnostic tests and medication levels.
✓ Enhance teamwork and communication skills with training and use of communication tools such as SBAR.
✓ Educate patients; obtain and document informed consent for surgery, procedures and medications with material risks using a patient-centered, shared decision making approach.
✓ Use simulation training to ensure technical skill and competence in performing surgical and routine procedures, as well as in equipment use.
✓ Provide education for clinic team members responsible for telephone or electronic communications with patients regarding symptoms or postoperative questions.