Communication and Resolution Programs Improve Patient Safety, Mitigate Risk

David B. Troxel, MD, Medical Director

The medical profession is part of the cultural shift happening throughout our society toward greater transparency—and this is benefiting physicians, as well as patients. I like to think that our profession has been a leader in this area with the movement to disclose medical errors, which began about twelve years ago. Because of this movement, many hospital systems are using communication and resolution programs (CRPs) to guide patients, families, physicians, and staff members when adverse events occur.  

We know now that when a medical error occurs, disclosure and transparency often reduce the patient's anger, and anger often leads to a medical liability claim. And greater transparency may mitigate risk on a larger scale as well: When analyses of adverse events leading to claims are made available to physicians, this often reduces their future occurrence, i.e., it reduces the risk of specific missed diagnoses, thus improving patient safety and reducing physician liability risks.

Transparency and Disclosure: With Individual Patients

CRPs teach hospitals, medical practices, and physicians how to respond to an adverse event. For example, medical professionals learn how best to respond when explaining why a wrong diagnosis was made or explaining why a pharmacy released the wrong medication. And CRPs stress the importance of offering to help, such as by reassuring the patient that healthcare costs resulting from the error may be ameliorated by fee reduction or waiver.  

At The Doctors Company, we encourage our physician members to participate in structured disclosure programs, and we provide resources to educate and assist them.

Transparency and Disclosure: Across the Profession

One of my main jobs as medical director of The Doctors Company is to review closed claims, both by specialty and by type of diagnostic error. Since we are the largest physician-owned medical malpractice insurance company in the United States, we have the largest claims database. By reviewing our closed claims data, we can achieve valuable insights, such as which diseases are most frequently misdiagnosed. By sharing our findings, we alert physicians to the most frequent causes of claims in their specialty, thus increasing patient safety and lowering physicians’ liability risks.

I can offer two examples of how studying our data, and distributing the results of our studies, have yielded positive outcomes for patients and physicians.

Difficult Diagnosis 1: Spinal Epidural Abscess. When we completed a study several years ago of closed claims in hospital medicine, the most common claim allegations were diagnosis related. Of these, we were surprised to see that there were a significant number of claims for missing a diagnosis of spinal epidural abscess.

Spinal epidural abscess is so uncommon that many physicians have never seen one. So we shared our study with the Society of Hospital Medicine, and they agreed to publish our study in their medical journal and present the findings at their national meetings. Meanwhile, I wrote an article on our findings in The Doctor’s Advocate, our quarterly publication. We’ve seen a gradual decline in the incidence of claims related to spinal epidural abscess as a result of sharing this data with physicians.

Difficult Diagnosis 2: Malignant Melanoma. Some time ago, after reviewing a large number of pathology claims, I was struck by the fact that the most common reason pathologists got sued was for missing a diagnosis of malignant melanoma. Like spinal epidural abscess, melanoma is well recognized as a difficult diagnosis because there are many variants of melanoma, some of which look benign. Unless you're seeing a large number of melanomas, you may not recognize the subtleties that lead to the correct diagnosis.

I shared this data with pathology specialty societies and published it in pathology journals. Additionally, I spoke on the subject at the societies’ national meetings, and they invited pathology experts to speak at their meetings on melanoma misdiagnosis.

About seven years ago, I looked to see if the dissemination of this information and the specialty societies’ educational programs had reduced the incidence of claims against pathologists involving melanoma. I was pleasantly surprised to see that the frequency of such claims had dropped dramatically.

Sharing closed claims data is one of the most important things we do at The Doctors Company. We encourage all physicians to review these studies.

Transparency and Disclosure: Optimism About Our Future

Within the medical profession, we’ve achieved positive momentum in terms of education for physicians to learn areas of practice where they need to be more attentive, and also for physicians to learn what to do if an adverse event occurs.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.