More malpractice payments were made in 2009 for adverse events that happened in the outpatient setting than in the inpatient setting, according to a report in the June 15 issue of JAMA.
The outcomes of adverse events among outpatients "were not trivial," with death and major injury accounting for nearly two-thirds of those claims, said Dr. Tara F. Bishop of the department of public health at Weill Cornell Medical College, New York, and her associates.
The findings may come as a surprise, given that most initiatives addressing patient safety have centered on inpatient care. "For example, in the past 5 years, the number of studies funded by the Agency for Healthcare Research and Quality on inpatient safety has been almost 10-fold that of outpatient studies," the investigators noted (JAMA 2011;305:2427-31).
"Our findings provide empirical support for suggestions that patient safety initiatives should focus on the outpatient setting, not just on inpatient care," they said.
The researchers assessed trends in malpractice payments using data from the National Practitioner Data Bank, "a repository of all malpractice payments paid on behalf of practitioners in the United States." They performed a retrospective analysis of payments involving only MDs and DOs, including residents, and compared payments for adverse events that occurred in inpatient settings with those that occurred in outpatient settings between 2005 and 2009, the first and last dates for which complete data were available.
The researchers noted that their results are underestimates of actual malpractice payments, because the NPDB doesn’t track payments made on behalf of corporate entities.
Adverse events were classified into six categories: diagnostic, surgical, obstetric, treatment/medication, anesthesia, or other. The outcomes of those adverse events were classified as involving death, lifelong care, major injury, minor injury, or emotional injury.
In 2009, 10,739 payments were made on malpractice claims against physicians. In all, 4,910 of those (48%) were for adverse events that occurred in an inpatient setting, 4,448 (43%) were for events that occurred in an outpatient setting, and 966 (9%) were for events that occurred in both settings.
Thus, more than half (52%) of the adverse events "occurred in the outpatient setting, at least in part," the investigators noted.
The average payment amount for outpatient malpractice claims was approximately $300,000, and that amount did not change over time. "Almost $1.3 billion in malpractice claims was paid for outpatient events in 2009," the investigators noted.
Major injury was the most common patient outcome in both settings, accounting for 38% of inpatient and 36% of outpatient claim payments. Death was the next most common patient outcome, accounting for 36% of the inpatient and 31% of the outpatient claim payments.
For outpatients, the most common types of adverse events were diagnostic (46%), treatment (30%), and surgical (14%). In contrast, the most common type of adverse events for inpatients was surgical (34%), followed by diagnostic (21%) and treatment (20%). That indicates that "more attention should be paid to adverse events related to diagnostic errors" in outpatient practice, Dr. Bishop and her colleagues said.
"Events related to diagnosis may be particularly important in the outpatient setting, where follow-up is more difficult than in the hospital and where patients often present with symptoms and signs that may be subtle or not adequately noted amid the many short-term, long-term, and preventive care activities often undertaken in a single outpatient visit," they added.
Moreover, "the importance of adverse events related to diagnosis may be particularly relevant as pay-for-performance and public reporting programs increasingly demand attention from clinicians," Dr. Bishop and her associates said. "These programs do not reward diagnostic acuity or punish diagnostic error and may divert clinicians’ time and attention from the critical area of diagnosis."
The number of malpractice claims declined significantly over time in both inpatient and outpatient settings, but the rate of the decrease was lower for outpatient claims.
Dr. Bishop was supported in part as a Nanette Laitman Clinical Scholar in Public Health at Weill Cornell Medical College. An associate was supported in part by a grant from the Agency for Healthcare Research and Quality.