Medication-related errors kill thousands of patients every year and rank among the most frequent — and potentially the most expensive — of allegations in medical malpractice lawsuits. Yet they also may be among the most easily preventable of medical errors, according to a Washington-based patient-safety advocacy group.
One solution being pushed by the Leapfrog Group, a consortium of Fortune 500 corporations and other health-care purchasers, is computerized entry of doctors' medication orders. Software that incorporates information about side effects or contraindications of specific drugs along with the patient's medical record may be able to intercept a potential medical error before the patient is ever given the wrong medicine.
The problem — and potential solution — illustrates one point emphasized by patient-safety experts but largely overlooked by doctors and lawyers in the medical malpractice debate: Many of the medical mistakes that give rise to malpractice lawsuits result more from system failures than from individual negligence.
“There are not enough systems and processes in place to provide checks and balances for the individual human beings who are called doctors, nurses or other caregivers,” says Suzanne Delbanco, Leapfrog Group's executive director. Health-care personnel “are treating people in an increasingly complex system,” she says, and are often quite simply taxed beyond their individual abilities.
While plaintiffs' lawyers and consumer groups emphasize malpractice lawsuits as an important way to encourage patient safety, the Leapfrog Group takes no position on liability issues. Instead, Delbanco says the group is seeking to “harness our joint purchasing power to drive significant improvements in the quality and value of health care.
“We're trying to educate consumers about the facts that quality of care varies from institution to institution,” she explains. “And we're trying to realign the incentives so that there's a reward at the end of the day for safety improvements.”
Several studies over the past decade have pointed to the largely unrecognized extent of injuries and deaths resulting from medical errors. The Institute of Medicine, a branch of the National Academy of Sciences, estimated in 1999 that medical errors account for 44,000 to 98,000 deaths per year — ranking as the ninth most frequent cause of death in the United States.
The Leapfrog Group decided to tackle the patient-safety issue by asking medical experts for a short list of well-researched recommendations that health-care consumers could readily understand and health-care providers could readily put into effect. They came up with a list of three, including the recommendation for computer entry of medication orders. The other two were assignment of properly trained specialists to intensive care units (ICUs) and referral of high-risk surgeries and high-risk neonatal cases to institutions best able to provide care for those conditions.
Each of the three recommendations faces significant practical obstacles. For computer entry of medication orders, the barriers include expense and the limited availability of software. So far, about 5 percent of the nation's hospitals have adopted the practice, Delbanco says. But vendors are developing more software, and more hospitals are indicating interest in the idea, she says.
For ICUs, the problem is quite simple: a shortage of doctors who have special training in critical care along with their regular specialties, Delbanco says. Only 10 percent of hospitals have properly trained critical-care specialists today, Delbanco says, but studies indicate that with proper staffing patient mortality can be reduced by nearly 30 percent.
Lack of information is the barrier to referring high-risk surgeries and neonatal cases to appropriate institutions, Delbanco says. Only a handful of states require hospitals to report patient outcomes for specified procedures. “In most states you're completely in the dark in choosing a hospital,” she explains. To remedy the information gap, Leapfrog Group is establishing voluntary reporting systems — and is getting good cooperation from hospitals in many parts of the country.
Malpractice insurers can help drive patient-safety improvements by lowering premiums for hospitals that adopt recommended practices, she points out. As for malpractice litigation, the effects remain to be seen, she says. “Presumably these practices would reduce errors and one would presume fewer people would sue,” she says. “But I don't know if we could perfectly correlate that.”
De Ville, Kenneth , Medical Malpractice in Nineteenth-Century America: Origins and Legacy, New York University Press, 1990.
Traces history of medical-malpractice litigation in the United States in the 1800s. DeVille is a professor at East Carolina University School of Medicine. For a shorter overview covering both the 19th and 20th centuries, see De Ville's article, “Medical Malpractice in Twentieth Century United States: The Interaction of Technology, Law and Culture,” International Journal of Technology Assessment in Health Care, Vol. 14, No. 2 (1998), pp. 197-211.
Kapp, Marshall B. , Our Hands Are Tied: Legal Tensions and Medical Ethics, Auburn House, 1998.
Critically examines reasons for “crisis mentality” regarding medical malpractice among U.S. physicians. Includes references after each chapter. Kapp is a professor of community health and psychiatry at Wright State University School of Medicine and adjunct professor at University of Dayton School of Law.
Sloan, Frank A. , et al., Suing for Medical Malpractice, University of Chicago Press, 1993.
Survey of malpractice claims filed in Florida at the peak of the medical-malpractice crisis in the late 1980s indicated most cases were well grounded and claimants on average were substantially under-compensated. Includes detailed notes, tabular material and 16-page bibliography. Lead author Sloan is director of the Center for Health Policy, Law and Management at Duke University.
Vidmar, Neil , Medical Malpractice and the American Jury: Confronting the Myths about Jury Incompetence, Deep Pockets and Outrageous Damage Awards, University of Michigan Press, 1995.
Review of medical-malpractice litigation nationally and detailed examination in North Carolina refutes critics' arguments that juries sympathize with patients over doctors or vote awards out of proportion to claimants' economic losses. Includes chapter notes, 11-page list of references. Vidmar is a professor at Duke University Law School.
Weiler, Paul C. , et al., A Measure of Malpractice: Medical Injury, Malpractice Litigation and Patient Compensation, Harvard University Press, 1993.
Study by team of Harvard scholars of hospital admissions in New York found injury-causing medical mistakes occurred in nearly 5 percent of cases, while malpractice claims were filed in a small fraction of such cases. Lead author Weiler had previewed findings in his earlier work, Medical Malpractice on Trial (Harvard University Press, 1991), which explicitly called for a no-fault system to ensure compensation for patients injured by medical mistakes.
“Doctor Dilemma,” The Charleston (W. Va.) Gazette
, Nov. 10, 2002-Dec. 1, 2002 (http://www.wvgazette.com).
The four-part series examined medical-malpractice issues from doctors' and patients' perspectives. An earlier series of stories pointedly challenged doctors' claims of a medical-malpractice crisis in the state. See “The Practice of Medicine,” Feb. 25-27, 2001.
Reports and Studies
Americans for Insurance Reform , “Medical Malpractice Insurance: Stable Losses/Unstable Rates,” Oct. 10, 2002 (www.insurance-reform.org).
Consumer coalition's analysis of medical-malpractice liability over three decades indicates payouts have been relatively stable since the 1980s, while insurance premiums have fallen or risen with the economic cycle. Web site includes separate analyses for New Jersey, Pennsylvania and West Virginia.
Corrigan, Janet M., Ann Greiner, and Shari M. Erickson (eds.), “Fostering Rapid Advances in Health Care: Learning from System Demonstrations,” Institute of Medicine, November 2002.
Report proposes various health care improvement demonstration projects, including non-judicial compensation schemes for patients injured by medical error.
Kohn, Linda, Janet Corrigan, and Molla Donaldson , “To Err Is Human: Building a Safer Health System,” Institute of Medicine, 1999 (http://books.nap.edu).
Medical errors result in at least 44,000 deaths and cost $17 billion to $29 billion each year, according to authors of 223-page report; comprehensive list of patient safety recommendations; no specific position on medical-liability issues. Includes detailed notes, references, appendices.
U.S. Department of Health and Human Services , “Confronting the New Health Care Crisis: Improving Health Care Quality and Lowering Costs By Fixing Our Medical Liability System,” July 24, 2002 (www.aspe.hhs.gov/daltcp/reports/litrefm.htm).
Twenty-eight page report says “extreme judgments” in “small proportion” of medical-malpractice cases are creating a litigation crisis that threatens quality of and access to health care; cites proposals by President Bush to cap damages, impose other restrictions.