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2006 Malcolm Baldrige National Quality Award Reipient


September 2009

Dear Colleague:

Our lead story this month confirms that saying I am sorry is still the best approach after medical errors. Follow the Safety Institute on Twitter for breaking news.


Gina Pugliese, editor
Vice President, Premier Safety Institute




Honesty and apology after medical errors result in 55 percent reduction in malpractice claims

Open communication and honesty with patients about medical errors, including an apology, were found to be the key to reducing malpractice claims by as much as 55 percent.

The evidence appears to support the position that patients file malpractice lawsuits because they get so angry when communication, honesty, accountability, and literally good customer service are lacking after a perceived error. A lawsuit is often the only way to find out what actually happened to a loved one. This position was addressed in a recent
commentary in the British Medical Journal (BMJ) referencing decades of evidence published by “Sorry Works!,” a coalition led by Doug Wojcieszak.

The University of Michigan Health System (UMHS) has adopted many of these strategies, including an apology after a medical error that resulted in
a greater than 50 percent reduction in average litigation costs and reduced malpractice claims by 55 percent between 1999 and 2006. UMHS published its
effective strategy for reducing litigation and malpractice claims. The article notes that a principled accounting of what occurred is best not only for patients and their families and the institution, but also for the healthcare providers involved in the event, future patients and even the lawyers. In addition to the policy of owning up to responsibility for adverse events, apologizing, and compensation to the patient and family as the core of the program, UMHS has a comprehensive patient safety initiative that includes other structural and cultural changes.

Other organization’s disclosure programs UMHS isn’t the only organization to implement a comprehensive disclosure program. The Department of Veterans Affairs, the University of Illinois at Chicago (UIC) Medical Center, and Kaiser Permanente also have well-developed programs of apology and disclosure. As originally developed by UMHC and enhanced by the UIC, principles of “full disclosure” include the following elements:

  • Provide effective and honest communication to patients and families following adverse patient events;
  • Apologize and compensate quickly and fairly when inappropriate medical care causes injury;
  • Defend medically appropriate care vigorously; and
  • Reduce patient injuries and claims by learning from past experience.

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AHRQ post-op VTE patient safety indicator not ready for prime time as reliable reporting tool

The patient safety indicator (PSI) screen for postoperative venous thromboembolism (VTE) performs well as a screening tool but is not a reliable tool for reporting.

The Agency for Healthcare Research and Quality’s (AHRQ) set of patient safety indicators (PSI) for potentially preventable complications in hospitalized patients was tested in a
recent study to identify cases of postoperative deep venous thromboembolism (DVT). Results of chart review revealed identification of nearly all true DVT cases, but also identified a significant number of false positives. The researchers concluded that this PSI is a good screening tool but given the risk of false positive, is unreliable for reporting purposes.

VTE represents a significant source of morbidity and mortality. In addition, pulmonary embolism (PE) is one of the most common preventable causes of death in hospitals. DVT/PE following total knee or total hip replacement is one of the hospital-acquired conditions for which CMS will not make additional payment if there are no other co-morbidities. The AHRQ indicator for postoperative VTE relies on the current disease classification (ICD-9-CM) codes for DVT or PE in secondary diagnoses fields. The accuracy of ICD-9-CM codes for identifying specific outcomes has been the subject of much debate. This study responds to those questions by finding that while the PSI is a good screening tool, it could be improved with better coding methods. Importantly, use of performance data for such purposes imposes additional requirements for accuracy and reliability that the PSIs may not meet for public reporting criteria.

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Public report of adverse events – the
sensitivity of event detection will vary with tool and
method used

The sensitivity of three commonly used methods for adverse event detection varied significantly – raising caution about their use in public reporting.

Researchers in a recent study compared three available methods for detecting adverse events in hospitals – the
AHRQ patient safety indicators (PSIs), provider-reported events, and the
IHI Global Trigger Tool. The objective of this study was to compare patients who had been identified as having adverse events (AE), using these methods of detection.

Four percent of discharges in 2005 (60,500) from three Mayo Clinic hospitals had an AE identified by at least one of the two hospital-wide methods – AHRQ (2.6 percent) and provider database (1.5 percent). Only
6 percent of hospitalizations with a PSI also had a provider-reported event, and only 10.5 percent of provider-reported events had a PSI, with a very small overlap. Using the IHI Global Trigger tool as an additional method to review a sample of cases, the trigger tool detected only 6 percent of AE detected by the other two methods.

Based on their findings, the authors suggest that measuring safety requires a multifaceted approach, and they caution against using any one indicator for public reporting and performance comparisons.

One reason for the discrepancies is that these commonly used patient safety measures are derived from different data sources and codes, often with different purposes, methods, dimensions of the care processes, and levels of patient harm.

  • PSIs are based on retrospective review of ICD-9 diagnosis codes from hospital discharge abstracts. They screen for patient safety events that appear to have occurred. In this study, the PSIs were modified to exclude “present on admission” diagnoses, reducing the likelihood of false positives.
  • Provider reported events are events reported as part of routine hospital and clinical activities. Data are entered into a central database with a locally developed tool.
  • Trigger tools are sentinel words or conditions found in a relatively quick review of the medical record to detect the possibility of the occurrence of an adverse event. The presence of one of these conditions