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Disclosure How to Avoid Adding Insult to Injury

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Disclosure How to Avoid Adding Insult to Injury Powered By Docstoc
					Expanding Patient Safety from
Malpractice Claims
Areas of Missed Opportunities




Matson Sewell CPHRM
Dartmouth-Hitchcock
Risk Management
Traditional Patient Safety Initiatives
          Medication errors
          IV extravasations
          Patient falls
          Transfusion errors
          Inpatient suicides
          Infant abduction
          Decubitus ulcers
Safety Problems Identified By
Malpractice Claims – Large Losses

   Catastrophic ob outcomes
   Neurologically impaired newborns
   Failure to diagnose cancer
   Delay in diagnosing. . .
   Surgical mishaps
Dartmouth-Hitchcock:
Uniquely positioned to Explore
Claims-Based Patient Safety
   Risk/Claims relationship with staff
   Size/configuration of program
   Early reporting
   Thorough investigations
   Claims feedback to clinicians
Obstetrics
 VBAC – A tale of two cases
 It was not about the lack of medical
  intervention
 NH case outcome

 Maine case outcome

 Intra-labor informed consent
Delay in Diagnosis of
Breast Cancer

   Big Malpractice Jury Award
   Analysis of claim files
   Newsletter/staff education
   Audit of clinical records
   Feedback to clinicians
   New emphasis identified
Examples of Never-Should-Happen


 Traditional: wrong site/patient   surgery
 FromClaim File Review:
 Sexual Misconduct
Boundary Violation
Interventions
   Starting in 1997
   Newsletters
   Seminars
   Staff meetings
   New staff orientation
   Videotape
   Breach in
standard of care
   Breach in
standard of care
“When We Knew Better, We Did Better”

Preventability- if not
 the first time, then
every time thereafter

 Honor The Injured by
Correcting the Problem
Expanding the Vision: New roles for

   Hospital  Administrators
   Risk Managers
   Claims Investigators
   Defense Attorneys
   Plaintiff Attorneys
   The ATLA

				
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posted:8/27/2011
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