How Claims History Can Assist Risk Management

Past performance can be a good predictor of future behavior. Reviewing the malpractice claims history for both your organization and your industry can help you identify potential exposures, improve related procedures, manage risks, and prevent future claims. To provide some insight into industry trends, this article shares key takeaways from Coverys closed malpractice claims data from 2018 to 2022.
 

Overview

The following statistics show Coverys claims frequency and severity for the five-year period between 2018 and 2022.

• Between 2018 and 2022, Coverys opened an average of 2,797 claims per year. The highest volume of claims occurred in 2020 (with 3,235) and the lowest volume of claims occurred in 2022 (with 2,247 claims).
• The average indemnity paid was $396,727. Indemnity payments were consistent over the five-year period, with a high of $434,983 in 2020 and a low of $372,156 in 2021.
• The percentage of closed claims with indemnity payments has increased. Between 2018 and 2020, it was 21% to 22%, increasing to 25% in 2021 and then to 28% in 2022.
• Nearly half (45%) of indemnity payments were between $100,000 and $500,000. Of the remaining, 26% were greater than $500,000 and 29% were less than $100,000.
• Nearly half (43%) of all claims were for incidents that resulted in death or high injury severity. This includes major permanent injuries, the need for lifelong care, or a fatal prognosis. These claims accounted for 66% of paid indemnity.

Top Allegation Categories

Some allegation types seem more likely to lead to malpractice claims than others.

• Diagnosis-related allegations were the leading cause of claims, accounting for more than 25% of claims and nearly 40% of indemnity paid. Diagnosis-related claims frequently involved allegations of negligent patient evaluation, interpretation of tests, or ordering of tests. There were also allegations involving referral management and follow-up. Case examples included failure to diagnose a cancerous mass, resulting in metastasis and death; failure to evaluate a patient, resulting in cardiac arrest and death; and failure to diagnose an evolving stroke, resulting in thromboembolic stroke and permanent brain damage.
• Surgery- and procedure-related allegations were the next leading cause of claims, accounting for around 25% of claims and more than 20% of indemnity paid. Most of these claims involved technical performance. However, there were also allegations of retained foreign bodies, unnecessary procedures, delays in surgery, and wrong side/site/patient.
• Medical treatment-related allegations accounted for more than 10% of claims and around 5% of indemnity paid.
• Medication-related allegations accounted for close to 10% of claims and more than 5% of indemnity paid.
• Obstetrics-related allegations accounted for around 5% of claims and 10% of indemnity paid.
• Patient environment- and safety-related allegations accounted for less than 5% of claims and indemnity paid.

Top Risk Exposures

In addition to identifying the main types of allegations, it’s important to assess the underlying exposures. In order of prevalence, these were:

• Clinical decision-making – Narrow diagnostic focus and inadequate or inappropriate testing or patient assessment.
• Technical performance – Unexpected technical problems as well as poor clinical judgment and inadequate skills.
• Clinical systems – Insufficient studies, failure to manage the patient’s follow-up care, and a lack of care coordination.
• Communication issues – Communication to or from practitioners, inadequate informed consent, and problems with communication between the practitioner and patient.
• Administrative issues – The need for policy or protocol and staff education. In some cases, policies or protocols existed but staff did not follow them.
• Behavior issues –Patients who did not agree with or adhere to the treatment plan, patients who were unhappy with their results, and inappropriate patient behavior.
• Medication issues – Adverse reactions, a failure or delay in prescribing, and other issues with prescriptions.
• Electronic health records – Documentation issues, a lack of active or updated medication lists, and confusing or limited system design.

The Impact of COVID-19

Many organizations are concerned about the impact of COVID-19, which may have delayed diagnoses and could lead to extended statutes of limitations. As of June 2023, Coverys received 231 COVID-related claims.

The most common allegation for claims related to COVID-19 involved patient environment and safety, including allegations of failure to prevent transmission of infection. Diagnosis-related allegations were less common and included the use of tests that gave a false positive and/or treatments that were not FDA approved. Approximately one-third of COVID-19 claims occurred in inpatient room settings. Another third occurred in correctional facility settings.
 

Risk Mitigation Strategies

Since diagnostic-related allegations were the leading cause of claims, strategies that address diagnostic accuracy have the greatest potential to improve patient safety and reduce claims frequency. Following are key risk mitigation strategies to increase diagnostic accuracy:

• Foster patient engagement. Consider patients and their families as part of the care team and provide opportunities for them to ask questions and give feedback. Since patient records can also play a role in engagement, practitioners should be educated on open notes and the use of plain language principles. Finally, practitioners should encourage patients to review their health information and records.
• Leverage education and data to reduce diagnostic error. Since cognitive biases can lead to errors, it’s important to educate practitioners on how to recognize their own biases. Data collection, integration, and verification systems can aid with knowledge deficits.
• Obtain informed patient consent. Increase patient comprehension by using plain language, written materials, and diagrams to supplement verbal conversations, and qualified interpreters and auxiliary aids, when appropriate. 
• Identify the root causes of diagnostic errors in your practice. Errors and near misses can provide actionable insights. You can use this information to educate your team and brainstorm evidence-based resources to help with the development of mitigation strategies.
• Support decision-making. Evidence-based decision support systems, clinical guidelines, checklists, and pathways can foster better decision-making.
• Develop a standardized process to correct inaccuracies. When you find inaccurate data and diagnoses in the electronic health record, follow a standard protocol to make corrections.

Design a Targeted Approach

To improve your organization’s claims experience, design targeted risk management strategies to address the specific allegations you’ve been experiencing. Here are two examples: 
 

1. To reduce claims alleging technical performance issues, determine the necessary qualifications for all practitioners and staff involved in care. Implement continuing surveillance of professional performance, including ongoing and focused professional practice evaluation and peer review. Also implement policies and procedures to guide and support the delivery of care.

2. To improve clinical systems and communication, implement standardized systems of communication. For example, how is your practice communicating diagnostic information between providers and staff and between various clinical or diagnostic areas and departments? How are you communicating incidental findings, abnormal results, overreads, and referrals? Use evidence-based tools to improve communication.

The key is to treat every claim as an invaluable opportunity to identify exposures, implement evidence-based solutions, and improve patient outcomes.

This article is based, in part, on a Coverys presentation “What’s New with Claim Trends,” presented by Dana N. Taylor, MHA, CPHRM, CPPS, Risk Management Consultant.


Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.