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Connecticut Post (Bridgeport, CT)

Study Finds Negligent Care Likelier in Outpatient Settings

by Staff Writers
April 3, 2004

FRIDAY, April 2 [HealthDayNews] -- Serious medical errors occur more frequently in outpatient settings than in hospitals, a new study of malpractice claims finds.

The study, which looked at 15 years of negligence claims involving primary care doctors, found that 68 percent of them arose from events in outpatient settings, such as doctors' offices and community clinics.

The volume of outpatient mishaps is partly a numbers game. "One in five people in America get seen in the outpatient setting every month, but only eight people in 100 wind up in a hospital each month," said the study's lead author, Dr. Robert L. Phillips, Jr., assistant director of the Robert Graham Center, the policy arm of the American Academy of Family Physicians.

The analysis appears in the April edition of the journal Quality and Safety in Health Care.

While the study does not look at claims against specialists, primary care physicians provide services both in and out of the hospital.

Jamie Court, president of the Foundation for Taxpayer and Consumer Rights in Santa Monica, Calif., isn't surprised that more patients are being harmed in outpatient settings, considering the volume and complexity of services provided outside of the hospital.

"I think this is a very interesting product of years of HMOs and giant hospital chains pushing to limit their overhead and kicking patients out too soon," he charged.

The authors combed 49,345 claims settled between 1985 and 2000 that involved
such primary care doctors as family physicians and general practitioners,
general internists, and general pediatricians.

The analysis focused on 5,921 claims judged to be the consequence of a negligent act. Those events resulted in more than 1,200 deaths in outpatient settings, vs. 809 inpatient deaths.

Heart attack topped the list of the 10 most common conditions that resulted in a negligence suit. But none of the top 10 conditions accounted for more than 5 percent of all claims.

Diagnostic errors appeared to be the underlying cause of 34 percent of the claims.

"A lot of people assume that the outpatient setting is not dangerous," Phillips stated. "In fact, there's a lot of harm occurring in the outpatient setting, and this should be an important focus of the effort to make patient care safer."

Yet much of the work being done across the United States to improve health-care quality and reduce medical errors has focused on inpatient care.

Why does outpatient care escape national attention? It may be because the most widely publicized negligence cases tend to involve egregious inpatient errors, such as the removal of the wrong leg of a patient or the administration of a lethal dose of medicine.

You don't see the same stories about what happens in the outpatient setting, Phillips said, and when you do, it's typically about a bad doctor.

In reality, he added, the study suggests many of the mistakes in primary care involve bad systems of care.

For example, 156 people died because something went wrong in how their medical records were handled. Problems with records were a contributing factor in 7 percent of the negligence claims. Communication problems between providers contributed to 72 deaths, or 2 percent of all negligence claims.

Some medical conditions trigger negligence claims at a much greater rate than they are seen in primary care settings. For instance, lawsuits resulting from errors in treating appendicitis are 20 times more likely to occur than lawsuits for breast cancer.

"That actually opened a lot of questions for us," he said.

Analyzing malpractice data may be a useful tool in helping doctors identify trouble sport and prevent future lapses in care, the authors concluded.

Next, Phillips said his team wants to obtain court documentation and peer review records for those malpractice cases to get a better grip on factors that led to those errors in the first place.

The federal Agency for Healthcare Research and Quality has more information at:
While the Centers for Medicare and Medicaid Services can tell you more about its initiatives for improving the quality of physician care.