The findings of the "CNA Hospital Professional Liability Claim Report 2015: Stepping Up to Quality Healthcare and Patient Safety," identify patient death as the most common injury in closed claims over the 10-year period analyzed in the insurance company's publication.
The report's analysis regarding patient deaths revealed that:
• Death is the most common injury, comprising 34.3 percent of the closed claims.
• Overall improper care was the allegation most frequently related to patient death, followed by allegations related to diagnosis or medication error in this data set reflecting 203 closed claims.
• Death was the most frequent injury outcome for:
o Emergency department-related claims (47.7 percent of 107 closed claims)
o Medication error-related claims (48.1 percent of 52 closed claims)
o Medicine patient and ambulatory care-related claims (50.7 percent of 138 closed claims)
o Pressure ulcers-related claims (41.9 percent of 31 closed claims)
One of the researchers noted that patient handoffs in an emergency department represent a significant vulnerability in the hospital setting. Frequently, healthcare professionals inadvertently fail to convey critical patient information to one another.
"Communication among healthcare providers is critical in any situation, but particularly in an emergency department," said Joyce Benton, assistant vice president of risk control for CNA. "Research has shown that ineffective or inadequate communication is a major factor in medical errors and near-misses, especially during handoffs and other transitions in care."
The Hospital Professional Liability Claim Report recommendations related to improving communication include:
• Train staff to use structured formats for exchanging information, such as the "Situation, Background, Assessment and Recommendation" method.
• Encourage use of the chain of command, and prohibit any retaliation on the part of colleagues or supervisors.
• Develop an effective procedure to manage diagnostic test result reporting and follow-up.