1. Unique Identifier 91278921
Author Localio AR; Lawthers AG; Brennan TA; Laird NM; Hebert LE; Peterson
LM; Newhouse JP; Weiler PC; Hiatt HH
Institution Center for Biostatistics and Epidemiology, Penn State University
College of Medicine, Hershey 17033.
Title Relation between malpractice claims and adverse events due to
negligence. Results of the Harvard Medical Practice Study III [see comments]
Source N Engl J Med 1991 Jul 25;325(4): p245-51
ISSN 0028-4793
Abstract
BACKGROUND AND METHODS. By matching the medical records of a random
sample of 31,429 patients hospitalized in New York State in 1984 with statewide
data on medical-malpractice claims, we identified patients who had filed
claims against physicians and hospitals. These results were then compared
with our findings, based on a review of the same medical records, regarding
the incidence of injuries to patients caused by medical management (adverse
events).
RESULTS. We identified 47 malpractice claims among 30,195 patients'
records located on our initial visits to the hospitals, and 4 claims among
580 additional records located during follow-up visits. The overall rate
of claims per discharge (weighted) was 0.13 percent (95 percent confidence
interval, 0.076 to 0.18 percent). Of the 280 patients who had adverse events
caused by medical negligence as defined by the study protocol, 8 filed malpractice
claims (weighted rate, 1.53 percent; 95 percent confidence interval, 0 to
3.2 percent). By contrast, our estimate of the statewide ratio of adverse
events caused by negligence (27,179) to malpractice claims (3570) is 7.6
to 1. This relative frequency overstates the chances that a negligent adverse
event will produce a claim, however, because most of the events for which
claims were made in the sample did not meet our definition of adverse events
due to negligence.
CONCLUSIONS. Medical-malpractice litigation infrequently compensates
patients injured by medical negligence and rarely identifies, and holds
providers accountable for, substandard care.
2. Unique Identifier 20181279
Author Thomas EJ; Studdert DM; Burstin HR; Orav EJ; Zeena T; Williams
EJ; Howard KM; Weiler PC; Brennan TA
Institution Department of Medicine, Brigham and Women's Hospital, Boston,
Massachusetts, USA. ethomas@heart.med.uth.tmc.edu.
Title Incidence and types of adverse events and negligent care in Utah
and Colorado [see comments]
Source Med Care 2000 Mar;38(3): p261-71
ISSN 0025-7079
Abstract
BACKGROUND: The ongoing debate on the incidence and types of iatrogenic
injuries in American hospitals has been informed primarily by the Harvard
Medical Practice Study, which analyzed hospitalizations in New York in 1984.
The generalizability of these findings is unknown and has been questioned
by other studies.
OBJECTIVE: We used methods similar to the Harvard Medical Practice
Study to estimate the incidence and types of adverse events and negligent
adverse events in Utah and Colorado in 1992.
DESIGN AND SUBJECTS: We selected a representative sample of hospitals
from Utah and Colorado and then randomly sampled 15,000 nonpsychiatric 1992
discharges. Each record was screened by a trained nurse-reviewer for 1 of
18 criteria associated with adverse events. If > or =1 criteria were
present, the record was reviewed by a trained physician to determine whether
an adverse event or negligent adverse event occurred and to classify the
type of adverse event.
MEASURES: The measures were adverse events and negligent adverse
events.
RESULTS: Adverse events occurred in 2.9+/-0.2% (mean+/-SD) of hospitalizations
in each state. In Utah, 32.6+/-4% of adverse events were due to negligence;
in Colorado, 27.4+/-2.4%. Death occurred in 6.6+/-1.2% of adverse events
and 8.8+/-2.5% of negligent adverse events. Operative adverse events comprised
44.9% of all adverse events; 16.9% were negligent, and 16.6% resulted in
permanent disability. Adverse drug events were the leading cause of nonoperative
adverse events (19.3% of all adverse events; 35.1% were negligent, and 9.7%
caused permanent disability). Most adverse events were attributed to surgeons
(46.1%, 22.3% negligent) and internists (23.2%, 44.9% negligent).
CONCLUSIONS: The incidence and types of adverse events in Utah and
Colorado in 1992 were similar to those in New York State in 1984. Iatrogenic
injury continues to be a significant public health problem. Improving systems
of surgical care and drug delivery could substantially reduce the burden
of iatrogenic injury.
3. Unique Identifier 20181278
Author Studdert DM; Thomas EJ; Burstin HR; Zbar BI; Orav EJ; Brennan
TA
Institution Department of Health Policy and Management, Harvard School
of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.
studdert@rand.org.
Title Negligent care and malpractice claiming behavior in Utah and
Colorado [see comments]
Source Med Care 2000 Mar;38(3): p250-60
ISSN 0025-7079
Abstract
BACKGROUND: Previous studies relating the incidence of negligent
medical care to malpractice lawsuits in the United States may not be generalizable.
These studies are based on data from 2 of the most populous states (California
and New York), collected more than a decade ago, during volatile periods
in the history of malpractice litigation.
OBJECTIVES: The study objectives were (1) to calculate how frequently
negligent and nonnegligent management of patients in Utah and Colorado in
1992 led to malpractice claims and (2) to understand the characteristics
of victims of negligent care who do not or cannot obtain compensation for
their injuries from the medical malpractice system.
DESIGN: We linked medical malpractice claims data from Utah and Colorado
with clinical data from a review of 14,700 medical records. We then analyzed
characteristics of claimants and nonclaimants using evidence from their
medical records about whether they had experienced a negligent adverse event.
MEASURES: The study measures were negligent adverse events and medical
malpractice claims.
RESULTS: Eighteen patients from our study sample filed claims: 14
were made in the absence of discernible negligence and 10 were made in the
absence of any adverse event. Of the patients who suffered negligent injury
in our study sample, 97% did not sue. Compared with patients who did sue
for negligence occurring in 1992, these nonclaimants were more likely to
be Medicare recipients (odds ratio [OR], 3.5; 95% CI [CI], 1.3 to 9.6),
Medicaid recipients (OR, 3.6; 95% CI, 1.4 to 9.0), > or =75 years of
age (OR, 7.0; 95% CI, 1.7 to 29.6), and low income earners (OR, 1.9; 95%
CI, 0.9 to 4.2) and to have suffered minor disability as a result of their
injury (OR, 6.3; 95% CI, 2.7 to 14.9).
CONCLUSIONS: The poor correlation between medical negligence and
malpractice claims that was present in New York in 1984 is also present
in Utah and Colorado in 1992. Paradoxically, the incidence of negligent
adverse events exceeds the incidence of malpractice claims but when a physician
is sued, there is a high probability that it will be for rendering nonnegligent
care. The elderly and the poor are particularly likely to be among those
who suffer negligence and do not sue, perhaps because their socioeconomic
status inhibits opportunities to secure legal representation.
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5. Unique Identifier 97074395
Author Posner KL; Caplan RA; Cheney FW
Institution Department of Anesthesiology, University of Washington
School of Medicine, Seattle 98195-6540, USA. posner@u.washington.edu.
Title Variation in expert opinion in medical malpractice review [published
erratum appears in Anesthesiology 1997 Mar; 86(3):754]
Source Anesthesiology 1996 Nov;85(5): p1049-54
ISSN 0003-3022
Abstract
BACKGROUND: Expert opinion in medical malpractice is a form
of implicit assessment, based on unstated individual opinion. This contrasts
with explicit assessment processes, which are characterized by criteria specified
and stated before the assessment. Although sources of bias that might hinder
the objectivity of expert witnesses have been identified, the effect of the
implicit nature of expert review has not been firmly established.
METHODS: Pairs of anesthesiologist-reviewers independently assessed
the appropriateness of care in anesthesia malpractice claims. With potential
sources of bias eliminated or held constant, the level of agreement was measured.
RESULTS: Thirty anesthesiologists reviewed 103 claims. Reviewers agreed
on 62% of claims and disagreed on 38%. They agreed that care was appropriate
in 27% and less than appropriate in 32%. Chance-corrected levels of agreement
were in the poor-good range (kappa = 0.37; 95% CI = 0.23 to 0.51). CONCLUSIONS:
Divergent opinion stemming from the implicit nature of expert review may be
common among objective medical experts reviewing malpractice claims.
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6. Unique Identifier 92130337
Author Goldman RL
Institution Quality Management Office, Department of Veterans Affairs
Central Office, Washington, DC 20420.
Title The reliability of peer assessments of quality of care [see comments]
Source JAMA 1992 Feb 19;267(7): p958-60
ISSN 0098-7484
Abstract
OBJECTIVE--To critically examine the literature regarding the interreviewer
reliability of the standard practice of peer assessment of quality of care.
DATA SOURCES--Computerized searches of the English-language literature
from 1966 through 1990 using MEDLINE, HEALTHLINE, and SCISEARCH databases
were performed to identify studies reporting data on interreviewer agreement
of implicit evaluations of patient care episodes.
STUDY SELECTION--Seventeen studies were identified. Five studies
were excluded from this review because of deficiencies in the methods or
lack of data on chance-corrected es of agreement.
DATA EXTRACTION SYNTHESIS--The degree of agreement beyond chance
was compared with accepted standards in the 12 remaining studies. Most of
these studies found agreement corrected for chance to be in the range regarded
as poor, indicating that physician agreement regarding quality of care is
only slightly better than the level expected by chance.
CONCLUSIONS--Given the magnitude of the resources devoted to quality
assurance and the centrality of peer assessment to these efforts, there
is a need for a global reexamination of the peer review process. A number
of proposals appear to have potential for improving the peer review process
including more objective assessment procedures, multiple reviewers, higher
standards for reviewers, elimination of systematic reviewer bias, use of
outcome judgements, and adoption of practice guidelines.
7. Unique Identifier 98374185
Author Levine RD; Sugarman M; Schiller W; Weinshel S; Lehning EJ; Lagasse
RS
Institution Department of Anesthesiology, Albert Einstein College of
Medicine/Montefiore Medical Center, Bronx, New York 10461-2373, USA. rdlevine@ix.netcom.com.
Title The effect of group discussion on interrater reliability of structured
peer review.
Source Anesthesiology 1998 Aug;89(2): p507-15
ISSN 0003-3022
8. Unique Identifier 92122343
Author Wilson DS; McElligott J; Fielding LP
Institution Department of Surgery, St. Mary's Hospital, Waterbury,
CT 06706.
Title Identification of preventable trauma deaths: confounded inquiries?
[see comments]
Source J Trauma 1992 Jan;32(1): p45-51
ISSN 0022-5282
Abstract
The published evaluation of methods for identifying preventable trauma
deaths contains many unstudied confounding factors. To investigate the reliability
of methods for identifying such preventable deaths, we compared three consensus
systems using separate five-member general review panels assessing 20 non-central
nervous system fatalities: panel A, independent judgments; panel B, discussion
of all cases preceding individual judgments; and panel C, independent judgments
followed by discussion and equivocal case reassignment. The Kappa concordance
was low for all methods (method A, 0.20; methods B and C, 0.40). Of
the 11 deaths judged preventable by at least one panel, only one death was
judged preventable by all three panels. Consensus agreement (four of five
assessors) was 20% for panel A, 45% for panel B, and 10% for panel C (difference
between panels B and C, p less than 0.03). In panel C, discussion affected
the rate of equivocal case designation from 30% to 5%. Thus different consensus
methods yielded different results. We conclude that individual case review
can be severely flawed and therefore should not be used to measure institutional
quality of patient care. We recommend that assessment of institutional performance
should be based on objective evaluation methods, which require the study
of patient population outcomes, rather than on subjective methods in which
individual cases are reviewed.
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