By Robert Hanscom, JD, Vice President of Business Analytics, Coverys

In many ways, outpatient surgery is safer than inpatient surgery, or so the data would make it appear. Year over year, the number and severity of malpractice claims related to outpatient surgery pale in comparison to inpatient surgery claims.
Yet it would be premature, even reckless, to assume that outpatient surgical departments and ambulatory surgery centers (ASCs) are proactively managing risk in the operating room.

To that point, what goes wrong in the inpatient setting also can occur in the outpatient environment. To effectively mitigate risk, it is important for all surgical teams to heed the warning signals found in historical claims data and, whether inpatient or ambulatory, remain vigilant about surgical safety vulnerabilities. Those warning signals include many factors, not the least of which are persistent issues with retained foreign objects and misidentification of patient or patient’s body part.
What follows is an overview of key insights from Coverys surgical claims data. While the majority of claims are related to inpatient cases, the processes, skills, and communications required to conduct surgery are nearly the same in outpatient and inpatient settings. As such, it is vital that we acknowledge the “safety gap” between outpatient and inpatient surgery might not last forever. Inpatient surgery can benefit from adopting some best practices from their outpatient brethren to improve their outcomes. Conversely, outpatient surgery facilities can work to maintain their record of safety by heeding warnings about the risks of inpatient surgeries so that habit or complacency do not expose them to risks that could have been foreseen.
What’s Going Well with Outpatient Surgery

Outpatient centers often excel in areas like providing good educational materials to patients and in having process-focused cultures. And, in general, they produce favorable patient health outcomes and patient satisfaction. The data, which we outline below, demonstrate what’s going well with outpatient surgery today; paying attention to the areas of differing outcomes between inpatient and outpatient is where the true lessons are to be found.
Of course, comparing outpatient and inpatient surgical data is not always an “apples to apples” proposition. The most complex and risky surgeries take place in the inpatient setting. As such, data averages for inpatient safety will be skewed to account for cases with high mortality (regardless of the skill of the surgeon or the presence of impeccable safety precautions) when compared to outpatient data.
Yet, because there are many types of surgical procedures offered in both inpatient and outpatient settings (like cosmetic procedures, gallbladder removal, and orthopedic procedures, just to name a few), and because the delivery of surgical services is often comparable regardless of location, comparing the outcomes of inpatient and outpatient surgeries can be instructive, valuable, and even predictive.  
We recently examined five consecutive years of malpractice claims data at Coverys (2011-2015) to see what differentiates outpatient claims from inpatient claims. The types of problems seen in both environments are nearly identical, though the severity and volume of issues is almost always worse in the inpatient setting.
Here’s what we found:
  • Substantially fewer claims were triggered from outpatient surgery—250% fewer than inpatient surgery claims.
  • Retained foreign object claims are lower in outpatient settings, representing 5.08% of outpatient surgical claims compared to 8.52% of inpatient claims.
  • Intubation-related claims are three times more frequent in the inpatient setting than they are in the outpatient setting.
  • High injury/severity claims (which include death) are lower in the outpatient setting. Nearly 20% of inpatient surgical claims were considered high injury/severity compared to 13% of outpatient surgical claims.
  • Improper surgical techniques related to an unexpected technical problem in the operating room are cited in approximately 19% of inpatient surgical claims versus 11% of outpatient claims.
  • Poor clinical judgment allegations occurred four times more frequently in inpatient claims compared to outpatient claims.
  • Misidentification of body part occurred in twice as many inpatient claims versus outpatient claims.
  • Failure to manage the patient’s follow-up care and issues related to patient monitoring in recovery were not cited at all in our outpatient claims data.
  • Appreciable disparities exist for some types of procedures or anatomical surgical areas when compared across inpatient and outpatient settings. For example, gastrointestinal surgeries are, by anatomical region, the most common type of surgery to trigger a claim in the hospital setting, yet in the outpatient setting, GI surgeries are the fifth most common type.
  • The highest percentage of claims for outpatient surgery are attributed to elective procedures that are dental or cosmetic in nature (like dental restoration, or laser and dermatology surgery), as well as orthopedic surgery (primarily carpal tunnel, foot, and knee surgery), and general surgery (mostly colonoscopy). For inpatient surgeries, however, the highest percentage of claims are related to cholecystectomy (gallbladder removal), hysterectomy, spinal surgery, knee surgery, and herniorrhaphy (hernia repair).
Whether you perform all or most of your surgeries in the inpatient or outpatient setting, you can apply this data in meaningful ways. An outpatient surgeon might ask, “Why are inpatient ORs having such poor outcomes with gallbladder removal? Have we simply been lucky in the outpatient setting, and is there something we can do to mitigate risks specific to the inpatient environment?” And an inpatient surgeon might ask, “Why are there so many fewer cases of poor clinical judgment in the outpatient setting? Is there something about their ORs ― like checklists or fewer distractions ― that could help us reduce those alarming numbers?”
The full collection of insights gleaned from our claims data analysis suggests that some key vulnerabilities experienced frequently in the hospital setting are being significantly better managed in the outpatient setting. Now, it’s time to ensure that we truly understand why. The worst thing we can do is simply accept the data without grasping its deeper learning. Doing so creates a divide in the world of surgery, assuming one group of professionals has found a “magic formula” for safety and that another group functions in an environment that, try as they might, is always going to be more dangerous. What we must do now is get these two groups talking ― sharing what they know, what they have seen, and what they have implemented in their own ORs ― all in the name of patient safety. There are lessons to be learned, not just from the data … but from each other.
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.