title: Surgical adverse events, risk management, and malpractice outcome: morbidity and mortality review is not enough.
abstract: OBJECTIVE
  To review all admissions (age > 13) to three surgical patient care centers at a single academic medical center between January 1, 1995, and December 6, 1999, for significant surgical adverse events.
  
  
  BACKGROUND
  Little data exist on the interrelationships between surgical adverse events, risk management, malpractice claims, and resulting indemnity payments to plaintiffs. The authors hypothesized that examination of this process would identify performance improvement opportunities overlooked by standard medical peer review; the risk of litigation would be constant across the three homogeneous patient care centers; and the risk management process would exceed the performance improvement process.
  
  
  METHODS
  Data collected included patient demographics (age, gender, and employment status), hospital financials (hospital charges, costs, and financial class), and outcome. Outcome categories were medical (disability: <1 month, 1-6 months, permanent/death), legal (no legal action, settlement, summary judgment), financial (indemnity payments, legal fees, write-offs), and cause and effect analysis. Cause and effect analysis attempts to identify system failures contributing to adverse outcomes. This was determined by two independent analysts using the 17 Harvard criteria and subdividing these into subsystem causative factors.
  
  
  RESULTS
  The study group consisted of 130 patients with surgical adverse events resulting in total liabilities of $8.2 million US dollars. The incidence of adverse events per 1,000 admissions across the three patient care centers was similar, but indemnity payments per 1,000 admissions varied (cardiothoracic = $30 US dollars, women's health = $90 US dollars, trauma = $520 US dollars). Patient demographics were not predictive of high-risk subgroups for adverse events or litigation. In terms of medical outcome, 51 patients had permanent disability or death, accounting for 98% of the indemnity payments. In terms of legal outcome, 103 patients received no indemnity payments, 15 patients received indemnity payments, four suits remain open, and in eight cases charges were written off ($0.121 million US dollars). To date, no cases have been adjudicated in court. Cause and effect analysis identified 390 system failures contributing to the adverse events (mean 3.0 failures per adverse event); there were 4.7 failures per adverse event in the 15 indemnity cases. Five categories of causes accounted for 75% of the failures (patient management, n = 104; communication, n = 89; administration, n = 33; documentation, n = 32; behavior, n = 23). The current medical review process would have identified 104 of 390 systems failures (37%).
  
  
  CONCLUSIONS
  This study demonstrates no rational link between the tort system and the reduction of adverse events. Sixty-three percent of contributing causes to adverse events were undetected by current medical review processes. Adverse events occur at the interface between different systems or disciplines and result from multiple failures. Indemnity costs per hospital day vary dramatically by patient care center (range $3.60-97.60 US dollars a day). The regionalization of healthcare is in jeopardy from the burden of high indemnity payments.
authors.affiliation: Section of Surgical Sciences, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 243 Medical Center South, 2100 Pierce Avenue, Nashville, TN 37212-3755, USA. john.morris@vanderbilt.edu
authors.forename: John A
authors.initials: JA
authors.lastname: Morris
authors.forename: Ysela
authors.initials: Y
authors.lastname: Carrillo
authors.forename: Judith M
authors.initials: JM
authors.lastname: Jenkins
authors.forename: Philip W
authors.initials: PW
authors.lastname: Smith
authors.forename: Sandy
authors.initials: S
authors.lastname: Bledsoe
authors.forename: James
authors.initials: J
authors.lastname: Pichert
authors.forename: Andrew
authors.initials: A
authors.lastname: White
mesh_terms: D000046:Academic Medical Centers / Q000191:economics / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D000328:Adult; D035881:Compensation and Redress / Q000331:legislation & jurisprudence; D005260:Female; D017721:Hospital Costs; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology* / Q000517:prevention & control; D016365:Liability, Legal / Q000191:economics; D008297:Male; D008318:Malpractice / Q000191:economics / Q000706:statistics & numerical data; D008485:Medical Audit; D019300:Medical Errors / Q000191:economics / Q000517:prevention & control / Q000706:statistics & numerical data; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology* / Q000517:prevention & control; D012308:Risk Management; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000191:economics / Q000331:legislation & jurisprudence*; D013597:Systems Analysis; D019616:Thoracic Surgical Procedures / Q000009:adverse effects / Q000191:economics / Q000331:legislation & jurisprudence; D014193:Trauma Centers / Q000191:economics / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data; D014481:United States; D016387:Women's Health