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Sutton’s Law

By Jock Hoffman, CRICO

Related to: Ambulatory, Diagnosis, Primary Care, Nursing, Obstetrics

No one should be surprised to learn that ambulatory care settings are as likely to be sued for malpractice as hospitals. To paraphrase Willie Sutton, it's where the patients are.

The recent publicity highlights two facts about contemporary health care: 1) complex care is steadily shifting from hospitals to ambulatory settings, and 2) most outpatient settings lack the proactive programs that have helped inpatient services identify and mitigate their patient safety risks.

In most hospitals, multiple individuals/departments are focused on patient safety as their primary task. They compile data and reports to identify chronic risks, they analyze adverse events to understand their root causes, and they develop and deliver training to help health care providers avoid the most egregious situations…and allegations of malpractice.

For outpatient practices, however, proactive patient safety improvement is rarely anyone’s full time job, and—too often—is an assignment added to the To Do list of somebody too busy to do too much to really help reduce risks. No doubt, physicians and nurses practicing in settings without a robust patient safety program want to be as safe as their inpatient colleagues. But without some fundamental understanding of their vulnerabilities, practice-based clinicians may under appreciate opportunities to focus on the problems specific to their environment.

Analysis of 8,157 malpractice cases in CRICO’s national database shows that 37 percent of cases stem from care delivered in an outpatient settings (excluding EDs). Missed or delayed diagnoses (31 percent) account for the largest portion of outpatient cases, followed by those involving missteps in medical treatment (30 percent), and those alleging a surgery-related error (14 percent). Not surprisingly, General Medicine and the medical subspecialties are the most commonly named services, accounting for 31 percent of the outpatient cases.

Hospitals have the staff and resources to dive deep into these type of broad statistics. They have access to additional data and narratives (e.g., incident reports, patient complaints, root cause analyses) to complement their malpractice data and help them triangulate the specific factors that contribute to their missed diagnoses (or surgery errors, or medical treatment mishaps, etc.). A hospital’s patient safety team armed with that level of detail and confidence is well positioned to act (e.g., initiate a project to monitor certain patient encounters, brainstorm with empathetic peers, seek funding for a pilot intervention). And, when a successful patient safety solution is implemented in one hospital department or location, other departments can replicate that effort.

Outpatient practices—with a growing share of the malpractice allegations, but an unequal ability to identify and address the underlying risks—need to be creative, innovative, and employ the power of numbers. In order to nourish a culture and environment that will sustain fundamental safety improvements, practice-based clinicians and administrators must find ways to:

  • build patient safety improvement into their work flow;
  • collect and analyze information that helps pinpoint fundamental hazards and systems shortcomings;
  • collaborate with peers and affiliates in order to share concerns, ideas, and best practices; and
  • lobby their parent organizations, malpractice insurers, and payors to support, resource, and reward their patient safety activities.

Just tell them, that’s where the patients are.


July 1, 2011
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