World Patient Safety Day

Today is the first-ever World Patient Safety Day, a global campaign launched by the World Health Organization to shine a light on patient safety in order to increase public awareness and spur engagement.

Patient safety is a driving mission behind the work we do at CRICO Strategies and we always appreciate the opportunity to shine a light on patient safety accomplishments that are being forged within our CBS Community. Our goal is to unite the medical and insurance communities into a single voice with credible and actionable data as our shared language. We do this through medical professional liability (MPL) data that are employed as evidence supporting risk reduction efforts for the insurance and health care delivery industries.

By working with national organizations that use our services, CBS data regularly serve as the underpinning of strategic initiatives to improve patient safety and reduce the likelihood of malpractice allegations. The below examples are excerpted from the CRICO Strategies CBS Report, Medical Malpractice in America: A 10-year Assessment with Insights.

CONSTELLATION MUTUAL

Concern: Underlying factors for missed or delayed diagnoses
MPL Analysis Finding: Outpatient diagnosis cases had the most breakdowns in the assessment phase (58%), along with 35% during the testing phase, and 45% during follow up.
Actions:

• web-based suite of bundled solutions for preventing diagnostic error
• clinic risk reports that highlight key vulnerabilities in outpatient practices
• individualized tracks for policyholders for preventing diagnostic error

FOJP/HOSPITALS INSURANCE COMPANY (NOW HEALTHCARE RISK ADVISORS)

Concern: Permanent injuries and MPL cases related to shoulder dystocia
MPL Analysis Finding: While clinical judgment factors were trending downward in Labor & Delivery cases, technical issues were trending upward.
Actions:

• teamwork training
• simulation course

THE DOCTORS COMPANY

Concern: Events that place cardiologists and their patients at risk
MPL Analysis Finding: Patient assessment issues are the most frequent cause of patient injury for cardiologists, especially failing to establish a differential diagnosis or ignoring available clinical information.
Actions:

• specialty-specific site assessments with study findings incorporated
• on-demand education featuring lessons from the analysis

MEDSTAR HEALTH

Concern: Misdiagnosed spinal injuries in the Emergency Department
MPL Analysis Finding: The misdiagnoses of injuries from atraumatic spinal cord compression were traced to communication challenges between ED physicians and the MRI suite.
Actions:

• system-wide interventions to support clinical judgment and improve communication
• web-based learning program to enhance diagnostic accuracy
• clinical pathway triggered in EHR when preliminary assessment suggests spinal cord compression

About CBS Data

The Comparative Benchmarking System (CBS) receives medical professional liability (MPL) cases from MPL insurers including open cases and cases closed without an indemnity payment. Each case is coded under a common (proprietary) taxonomy by clinical coding experts who receive ongoing training and auditing to ensure consistency and currency. The clinical coders have access to all records and documents produced for the management of the case, including medical records, expert review, depositions, and court proceedings. The CBS database contains cases from all 50 U.S. states and several territories (representing 30% of U.S. MPL cases) and adds roughly 9,000 new cases per year.