• Case study: reducing malpractice payouts, not by capping damage awards, but by reducing malpractice Friday, March 4, 2011

    Don’t forget: at the heart of the medical malpractice issue is medical malpractice. The goal of reducing the amount of money paid to people who have been injured by malpractice is a laudable one, but the object shouldn’t be just to increase insurance company profits.

    It turns out limiting damage awards to injured patients (or their survivors) isn’t the only way to reduce payouts; it’s certainly not the best one, since it’s patently unfair to, among others, children, the elderly, stay-at-home parents and people with low-to-moderate incomes. But a surefire way to reduce the amount of money paid to malpractice victims is to reduce the amount of malpractice.

    Dr. Amos Grünebaum

    That’s what New York Presbyterian/Weill Cornell Medical Center set out to do in 2002 in its obstetrics department — with astounding results. Writing in the February 2011 issue of the American Journal of Obstetrics & Gynecology, Drs. Amos Grünebaum, Frank Chervenak and Daniel Skupski described how average annual malpractice expenses (payouts plus cost of defense) dropped 90 percent after new practices were implemented. And the number of “sentinel events,” such as avoidable maternal deaths and serious newborn injuries, went from five in 2000 to zero in both 2008 and 2009.

    The authors say the focus on patient safety came at the initiative of the hospital’s insurance carrier, MCIC Vermont, Inc. Among the results:

    Regular team training programs are held “to empower every team member to speak up and intervene if an unsafe situation may be occurring.” The training involves “all staff working on labor and delivery including clerical staff, nurses, attending obstetricians, neonatologists, anesthesiologists, and residents.”

    “Good medical record charting can help defend professional liability cases and may persuade potential plaintiffs to forego filing a suit, and electronic health records on labor and delivery are less likely to miss key clinical information.” As a result paper documentation is not allowed unless the electronic system is down.

    “A gynecology attending on call schedule was established separately from the obstetric coverage….The added gynecology coverage allowed the labor and delivery attending to cover the labor floor exclusively.”

    Steps were taken to improve the safe use of magnesium sulfate, which is used to prevent premature labor, seizures and cerebral palsy. “Magnesium sulfate is among the most dangerous solutions used on labor and delivery…we implemented several changes, including the use of premixed magnesium sulfate and oxytocin solutions, color coded magnesium sulfate and oxytocin containers and intravenous lines, as well as using both with ‘smart pumps.'”

    The hospital now has a full-time obstetric patient safety nurse, who is “involved in staff education, team training, implementation of protocol changes on labor and delivery, obstetric emergency drills, and collection of data.”

    The traditional dry-erase whiteboard was replaced with an online electronic whiteboard that uses color-coded warning labels.

    Three additional obstetric physician assistants were hired to help with the workload.

    All staff involved in interpreting electronic fetal monitoring, including nurses, physician assistants, residents and attendings, have to be certified in its use.

    To reduce the incidents of pulmonary thromboembolism, which can be fatal and is among the leading causes of maternal deaths, the hospital began administering anticoagulant medication to high-risk patients and using lower-extremity pneumatic compression devices for all caesarean deliveries.

    There are regular emergency drills, using manikins, to provide additional training in dealing with some of the most dangerous delivery room situations: shoulder dystocia (when the head has emerged but the shoulder can’t), maternal hemorrhage and maternal cardiac arrest.

    The hospital added a laborist (an ob/gyn who works full-time delivering babies). “Sleep deprivation can impair safety…The hiring of a laborist allowed our obstetricians to work reduced inhospital hours and likely contributed to the improved safety climate and improved outcomes at our institution.”

    Regular reading assignments and tests are given to attendings and residents to keep them up-to-date on labor and delivery safety.

    The authors say the main goal of the changes was to improve patient safety. According to their report, “We did not expect a rapid and significant effect on compensation payments.”

    But that’s what happened. “Beginning with the fourth year of the program, compensation payments began to drop significantly….The $25,041,475 yearly savings in compensation payments for the last 3 years alone dwarf the incremental cost of the patient safety program…we expect significant savings to continue into the future.”

    New York does not mandate artificial limits on compensation for people who have been harmed by medical negligence. But even advocates of such caps wouldn’t dream of arguing that they would reduce malpractice expenses by 90 percent. New York Presbyterian/Weill Cornell found a way to achieve those savings in the best way possible: by reducing the number of patients harmed in the first place.

    –J.G. Preston

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  • Study: The poor and elderly are “silent victims” of the medical malpractice system

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