Magazine article Risk Management

Injury Prevention vs. Patient Communications

Magazine article Risk Management

Injury Prevention vs. Patient Communications

Article excerpt

Medical risk management has long been driven by two opposing schools of thought: the injury prevention approach and the human relations approach. Injury prevention is best illustrated by the American College of Surgeons' Patient Safety Manual, which by its very name reveals its preference. Human relations is typified by the Department of Health, Education and Welfare's 1973 Report of the Secretary's Commission on Medical Malpractice. It states: "There are those who believe the malpractice problem is essentially a human relations problem and that greater attention to the human component is the only sure solution."

Advocates of both schools have traditionally had difficulty reconciling their disparate views. Injury prevention proponents often use a review of closed claims to substantiate their theory. In 1984, for example, the General Accounting Office completed a review of more than 73,000 claims closed by 102 malpractice carriers. It found that the greatest percentage of claims resulted from errors in surgery, diagnosis and treatment. Using this information, injury prevention proponents structure their risk management programs to emphasize the need to avoid these mistakes. Indeed, most occurrence and generic screening criteria help identify these problems.

Human relations advocates acknowledge these statistics, yet say they do not reveal the true nature of malpractice claims. To bolster their argument, they cite the many malpractice claims made for temporary, emotional and minor injuries, suggesting that the injury itself may not be the principal cause of concern. They also point out that most potentially compensable injuries do not trigger liability claims. Finally, they cite the fact that family physicians and general internists have lower malpractice claims even though their technical training is not as extensive as subspecialists. According to these advocates, this suggests the protective value of a solid doctor-patient relationship.

Like descendants of the Tower of Babel, advocates of the two schools appear to speak different languages and operate from different assumptions, never resolving or synthesizing their perspectives. The malpractice pyramid offers a way to provide a common frame of reference and a coherent approach to risk management programs. It answers three basic questions: What percentage of patients experience a suboptimal outcome, and what are the contributing factors? What percentage of these outcomes involve negligence? What percentage of suboptimal outcomes result in claims?

The following analysis focuses on the hospital setting since these statistics are more readily available than figures from the ambulatory setting, and 80.5 percent of malpractice claims stem from incidents occurring in a hospital.

Suboptimal Outcomes

Studies reveal that many patients experience a complication, adverse drug reaction or iatrogenic condition during hospitalization. Research conducted for the Commission on Medical Malpractice in the early 1970s found that 5 percent to 7 percent of hospitalizations led to medical injury. In 1974 the California Medical and the California Hospital associations screened 20,864 patient records from 23 state hospitals and found that 4.6 percent of patients suffered an iatrogenic injury. Last year the Harvard School of Public Health released the findings of a study analyzing 31,429 records sampled from New York State hospitals that showed adverse incidents occurred in 3.7 percent of all hospitalizations. Relying on the California and Harvard studies, it is fair to say that about 4 percent of all hospitalizations involve an adverse occurrence.

Physical discomfort and injury are not the only dimensions affecting the perceived quality of the outcome-communication to the patient is also important. Communication ranges from explaining to patients clinical progress, discharge instructions and reasons for laboratory tests to addressing patients' psychosocial needs, which includes demonstrating courtesy, caring and compassion during a time of need. …

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