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  Many medical errors are preventable

  
  
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  Most medical malpractice claims can be avoided

  
  
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  Patient safety & quality must remain highly intentional

I recently retired from my position as medical director of Denver Health, a regional level I trauma center and academic safety net hospital. My career spanned nearly 30 years at Denver Health. Prior to my final job as medical director, I also spent many years as chief of internal medicine and chief medical officer.

During the last 15 or so years of my tenure at Denver Health, I became very involved in the formalization and growth of Denver Health’s Patient Safety and Quality Department. This was around the time that the Institute of Medicine seminal report, “Crossing the Quality Chasm,” was published. Concurrent with that, I also became closely involved with risk-management-type issues at Denver Health. Thus, my ability to reflect back on those experiences helped me to author this chapter.

From the outset, it is worth noting that Denver Health is fortunate to be included in the shelter provided by “governmental immunity,” and thus there was a relatively low maximum financial cap that lawsuits could achieve if they prevailed against Denver Health. This relatively small monetary cap definitely dissuaded attorneys from pursuing lawsuits against Denver Health. As a result, thankfully, I was somewhat limited in my exposure to medical malpractice claims, notwithstanding my long-term experience as a medical hospital executive.

This reality for me is worthy of deliberation because it does strongly support a need for tort reform in order to help rein in exploding healthcare costs. Statutory caps on damages are essential because liability premiums grew rapidly during the last 2 decades even though they recently have stabilized. Of note, as the monetary cap for damages from institutions covered by governmental immunity increases, medical malpractice suits also tend to increase. This also supports an overall need for statutory caps on damages as part of long-overdue tort reform in order to avert the expensive cost of defensive medicine.

Fear of malpractice is often cited as a strong driver of overuse of healthcare services and high healthcare spending. The cap on awards engendered by governmental immunity likely limited malpractice claims. The cap in Colorado was $250,000 whereas the mean payment amount for paid claims that were adjudicated in court approached $600,000 over the last 5 years. Moreover, almost half of claims judged in court resulted in payments greater than $1 million.

The epidemiology of the malpractice claims that I was involved in helping to resolve, in very general terms, was of 2 broad categories: errors of commission and errors of omission. Because Denver Health is an academic center, much of the day-to-day care is directly rendered by resident physicians enrolled in graduate medical education under the supervision of an attending physician, who ultimately has the primary responsibility for the care of a patient’s major condition or diagnosis. Therefore, the alleged errors that resulted in lawsuits were either related to potential flaws in the design of our teaching systems or more directly attributable to the actions of the residents (ie, latent errors and active errors).

In this regard, handoffs, the transfer of information from those residents finishing their shift, to the next group of on-call physicians, were indeed a cause of adverse events that resulted in lawsuits. This issue has drawn much-needed attention in the last few years. For many years the processes involved with this transfer of information were surprisingly very haphazard. Handwritten information was illegible and the extent of information transmitted varied from very minimal to comprehensive. Computerized and standardized sign-out procedures are now becoming more commonplace, and thus the heretofore problem of inadequate sign-out procedures is becoming less of an issue than it was during my years in the hospital.

Another issue, which definitely resulted in malpractice claims, related to the whole mantra of medical education. Although the adage, “see one, do one, teach one” has long been the mantra of housestaff, this ingrained philosophy is a perilous one. While there is little doubt that autonomy and education are basic tenets of graduate medical education, it was clearly evident in some of the malpractice events that a level of competence was lacking. Gaining the requisite level of competence by residents may not always guarantee the proficiency needed to ensure patient safety, but it is a reality of the evolution of that person’s traversing through housestaff training. Therefore, when lawsuits related to proficiency of the resident became manifest, insufficient competence was often a root cause of the adverse event. Once again, and thankfully, the Accreditation Council for Graduate Medical Education (ACGME) has increasingly promulgated standards for training to certify that residents are proficient in performing a number of procedures to achieve competence. ACGME has also encouraged workshop and training forums to standardize training and to improve clinical practice.

Work-Hour Restrictions

It is worth mentioning that resident work-hour restrictions were touted as being causative of serious medical errors at the hands of the residents. The thinking behind this was that cognitive function declines with the sleep deprivation that has long been inherent to resident on-call training. Thus in 2002, ACGME revealed a plan to limit residents’ work schedules to a maximum of 80 hours per week and to limit work shifts to a maximum of 24 hours with mandatory amounts of time off between shifts. The hope was that this mandate would not only reduce errors and malpractice suits, but it would also actually improve housestaff training in general. Parenthetically, as a hospital executive, it is worth noting that unequivocal benefit from this plan remained lacking as I headed into retirement.