Errors in Healthcare: A Review of Indemnity Awards in Surgery

1. Errors in Healthcare: A Review of Indemnity Awards in Surgery Jeffrey E. Carter, M.D. Bradshaw Research Fellow Department of General Surgery

2. Objectives: Participants will gain a perspective on recent developments in surgical education. Participants will be able to associate indemnity awards to medical errors. Participants will be able to associate cost-savings with error reduction.

3. Introduction Reform c.1200 Improvement; alteration for the better Revolution c.1390 Transfer of power or sovereignty Frank Opelka, M.D. 93rd American College of Surgeons Clinical Congress Algebra and physics high school teacherAlgebra and physics high school teacher

4. Disclosures: There are no relevant conflict of interests to disclose.

6. WFUBMC 1,200 bed tertiary care center Level 1 Trauma Center Hospital 5 million square feet 10,000 employees 1,400 faculty 650 Residents & Fellows 580 Medical, PA, & SRNA Students 40 Operating Rooms 100-140 Operations/day

7. Introduction 1999 ? Human Patient Simulation Lab Mike Olympio and Ian Saunders 2005 ?

8. Introduction 1999 ? Human Patient Simulation Lab 2005 ? Role of Simulation in Surgery & Safety 2006 ? Grand Rounds

10. Introduction 1999 ? Human Patient Simulation Lab 2005 ? Role of Simulation in Surgery & Safety 2006 ? Grand Rounds 2006 ? ACS AEI Criteria

11. Introduction 1999 ? Human Patient Simulation Lab 2005 ? Role of Simulation in Surgery & Safety 2006 ? Grand Rounds 2006 ? ACS AEI Criteria 2007 ? SCORE paper 2007 Bell R. Surgical Council on Resident Education: A New Organization Devoted to Graduate Surgical Education. JACS 2007;204:341-346.

13. Introduction 1999 ? Human Patient Simulation Lab 2005 ? Role of Simulation in Surgery & Safety 2006 ? Grand Rounds 2006 ? ACS AEI Criteria 2007 ? SCORE paper 2007 2007 ? ACGME RRC Program Requirement

15. Surgeons Through Time

16. Introduction 1999 ? Human Patient Simulation Lab 2005 ? Role of Simulation in Surgery & Safety 2006 ? Grand Rounds 2006 ? ACS AEI Criteria 2007 ? SCORE paper 2007 2007 ? ACGME RRC Program Requirement 2007 ? Curriculum Development

17. Joint Commission http://www.jointcommission.org/NR/rdonlyres/FA465646-5F5F-4543-AC8F-E8AF6571E372/0/root_cause_se.jpg

18. Introduction 2008 National Patient Safety Goals Improve the accuracy of patient safety Improve the effectiveness of communication among caregivers Improve the safety of using medications Reduce the risk of healthcare associated infections Accurately & completely reconcile medications across the continuum of care Reduce the risk of patient falls Encourage patients� active involvement in their own care as patient safety strategy The organization identifies safety risks inherent in its patient population Improve recognition & response to change in a patient�s condition Reduce the likelihood of patient harm associated with the use of anticoagulation therapy

19. Introduction ACGME Core Competencies: Professionalism Communication Practice-Based Learning Systems-Based Practice Medical Knowledge Patient Care

20. Introduction Needs Assessment What does a mistake cost? Risk Management Department

21. Introduction Curriculum Development Needs Assessment Frequency within our institution over 5 years Frequency nationwide Liable specialties Scenario development Cost of mistakes Reallocation of resources Predictive Validity

22. Concept 1979 AA Flight 191 DC-10 273 deaths, $100 million 1991-2000 Ford Explorer/Firestone Tires >203 deaths, $55 million Healthcare Industry $2 Trillion 2006 $602 million in 3,811 closed claims* 2004 $28.7 billion* IOM 98,000 preventable deaths (268 day) Lucian Leape at Harvard School of Public Health 120,000

24. Concept Tort Reform versus Prevention What would you want? Which is more empathetic? 6 Sigma in Error Proofing* 81% of all errors can be prevented

25. Concept Education can mitigate errors Cost savings to the healthcare industry and patients

26. Introduction �Predictive validity- the extent to which the simulator predicts future performance� McDougall EM. Validation of Surgical Simulators. Jour of Endourology 2007;21:244-247. McCarthy J, Cooper JB. Malpractice Insurance Carrier Provides Premium Incentive for Simulation-Based Training and Believes It Has Made a Difference. APSF Spring 2007 Newsletter CRICO: �the program was indeed effective� Lowered malpractice premiums 19% Anesthesia 10% Ob/Gyn

28. Introduction Goals: Define the average indemnity awards for sentinel events Pilot a curriculum based upon our institution�s needs assessment (2007-2008) Incorporate multidisciplinary curriculum with SCORE Phases 1, 2, & 3 Develop a competency-based scoring system for CRM Follow trends of sentinel events using PSN

29. Methods Risk Management subscribed to a monthly publication titled, �Medical Malpractice Monthly: Verdicts, Settlements, & Experts� Voluntarily reported by law firms nationwide Advertising for attorneys, expert witnesses Monthly publication out of Nashville, TN 150 cases/month 1989-2006 30,000 total cases ? 1,222 Surgical Cases http://www.verdictslaska.com/malpractice/index2.html

30. Methods Abstracted: Event Specialty Outcome Categorized Allergic Reactions Aspiration Failure to monitor Falls/Positioning Fire Award Amount State Year Medication Error Power/Equipment Failure Retained Foreign Body Venous Air Embolism Wrong Site Surgery

31. Results Total 1,222 Cases Median Award: $475,000 Mean Award: $1,738,406 Range: $6,500-$75,900,000 Example: Wrong Site Surgery ~75/yr* 75 x $262,000 = $19,650,000 10% effective = $1,965,000 *Joint Commission

35. Results Allergic Reactions 19 cases Median: $728,000 Range: $100,000-$3,750,000 Top 3 Liable Parties: Hospital 10 $1,273,900 Anesthesia 4 $1,500,000 General 2 $1,500,000

36. Results Aspiration 39 Cases Median: $600,000 Range: $37,000-$14,000,000 Top 3 Liable Parties: Anesthesia 19 $1,070,220 General 9 $806,889 Hospital 5 $794,000

37. Results Failure to Monitor 190 Cases Median: $1,100,000 Range: $15,000- $75,900,000 Top 3 Liable Parties: Hospital 80 $3,099,453 Anesthesia 63 $3,867,082 General 24 $2,001,127

38. Results Falls/Positioning 207 Cases Median: $225,000 Range: $7,000-$7,300,000 Top 3 Liable Parties: Hospital 134 $513,417 Orthopedics 23 $907,446 General 23 $502,413

39. Results Fire 5 Cases Median: $500,000 Range: $150,000-$7,000,000 Top 3 Liable Parties: ENT 2 $3,750,000 General 2 $550,000 Anesthesia 1 $150,000

40. Results Medication Error 145 Cases Median: $1,000,000 Range: $14,500-$52,000,000 Top 3 Liable Parties: Hospital 66 $1,909,475 Anesthesia 31 $5,817,219 General 16 $2,396,625

41. Results Power/Equipment Failure 92 Cases Median: $519,000 Range: $9,000- $27,000,000 Top 3 Liable Parties: General 21 $1,690,529 Hospital 16 $1,839,469 Anesthesia 12 $4,460,733 Ortho 12 $1,286,287

42. Results Retained Foreign Body 163 Cases Median: $150,000 Range: $6,500-$10,000,000 Top 3 Liable Parties: General 90 $367,964 Ob/Gyn 38 $851,878 Orthopedics 15 $489,127

43. Results Venous Air Embolism 24 Cases Median: $1,062,500 Range: $119,900-$24,700,000 Top 3 Liable Parties: General 8 $650,675 Ob/Gyn 6 $3,341,667 Hospital 5 $5,628,800

44. Results Wrong Site Surgery 136 Cases Median: $262,500 Range: $15,000-$6,000,000 Top 3 Liable Parties: Orthopedics 75 $317,016 Neurosurgery 34 $822,282 General 19 $904,737

45. Conclusions & Conflicts What can the risk management do for you? Aided in our scenario and curriculum development Who pays the malpractice insurance? Hospital or the School of Medicine CMS Pay 4 Performance: RFB, VAE, SSI, CRBSI, CRUTI, DVT/PE, VAP

46. Acknowledgements: Alexis D. Smith Ian Sanders & Sarah Bodin, MD Surgical Services at WFUBMC Beverly Essick, MSN, Chris Lyons, Steve Folmar, PhD, Tim Houle, PhD