Using the Scientific Method to Address Non-Clinical Risk Management

Timothy R. Bone, President, MedMal Direct Insurance Company // June 16, 2011

In the United States, we are very fortunate to have the finest physicians practicing the best clinical medicine in the world. Yet sadly, we also live in one of the most litigious societies in the world that is clearly not hesitant to file lawsuits against these same outstanding physicians. It is in the best interest of all physicians to eliminate, or at least mitigate, the sources of these lawsuits, regardless of whether these sources are clinical in origin.

It is always true that the very best risk management for any physician or healthcare provider is continuing education, which naturally emphasizes the clinical practice of medicine. But we can also significantly reduce the probability of a lawsuit being filed, and decrease the duration of a lawsuit that has been filed, by addressing the non-clinical issues.

It is commonly understood in healthcare risk management that 50% of the medical malpractice lawsuits arise from communication problems between human beings, 30% of those lawsuits arise from system errors and only 20% of the lawsuits filed against physicians arise from actual clinical problems. In this issue, and in the few issues that follow, we will begin to address some of the most common non-clinical problems by objectively approaching each issue and its resolution via the scientific method.

This format identifies the issue at hand, provides an “outcome goal” (or objective) and then offers a relatively simple approach to data-gathering via chart review, observations, or simple surveys. Obviously, each participant can enrich the specific approach if warranted, and can also share outcomes. Though these reviews take some effort, they have shown, over time, that they do achieve the stated goal: elimination or mitigation of the risk that leads to medical malpractice lawsuits.

VERBAL ORDERS – fraught with peril!

Issue: Misunderstanding or misinterpreting verbal orders – including telephone orders.

Solution: Determine what proportion of orders for patients in your hospital (or office) – if any – are verbal orders. Engage in subsequent dialogue to measure the appropriateness of the circumstances surrounding their use. The only total protection is avoidance of verbal orders; since this is not a feasible goal, their frequency should be kept to a minimum and appropriate indications for the use of verbal orders ought to be identified and monitored.

Review Procedure:
1. Obtain 50 charts for a sample of recently discharged patients, at least 10 of whom have spent time in intensive care, coronary care or the labor suite. 
2. Review all the orders and tallythe total number of orders written – i.e., either individual or group entries to constitute the denominator. Determine how many verbal orders had been issued and let that number serve as the numerator. 
3. Tally the totals in both groups and determine what percentage of the total orders was composed of verbal orders. 
4. If the percentage exceeds 5 percent for the total sample, prepare a proposed listing of appropriate indications for the use of verbal orders and submit them to the Medical Executive Committee for their consideration.

Actions To Be Taken:
1. If all is in order, so notify the Medical Executive Committee and the medical staff at the next staff meeting. 
2. If a problem exists, devise the recommended list of appropriate indications for your Medical Executive Committee, bring it to them for their action, and, if implemented, re-audit the process six months hence.

Added Point of Emphasis. 
1. One hospital, priding itself on the accuracy, legibility, and completeness of its order sheets, was stunned to discover that approximately 14 percent of orders of non-intensive care medical patients were verbal orders. With so many similar-sounding names of medication, such practices are fraught with problems. 
2. Another hospital has noted that this problem of accurate verbal communication is also greatly increased in today’s healthcare environment simply because so many physicians and healthcare providers do not speak English as their primary language. Pronunciations of words are different and are easily misunderstood or misinterpreted. It is thus more important than ever that the electronic medical record be used to accurately document all communications.

Remember that only 20% of all medical malpractice lawsuits brought against physicians arise from actual clinical error. That leaves an astonishing 80% of all medmal suits that could be avoided through the simple modification of non-clinical procedures. It is worth the small investment in time to perform an analysis of your systems that may greatly decrease the chance of a lawsuit being brought against you.