By Charles A. Pilcher MD FACEP
January, 2015
New Publication: Medical Malpractice Insights – Learning From Lawsuits
Physicians are learning nothing from the outcome of medical malpractice lawsuits. That must change. Now.
Seeing the same mistakes being made again and again by presumably competent physicians is frustrating. We physicians don’t have a clue – unless we ourselves are the defendants – what causes our colleagues to get sued.
For example, in the past few years I have been involved in 3 cases of missed aortic dissection, 3 cases of missed spinal epidural abscess, several missed strokes, missed appendicitis, several missed or under-treated fractures and dislocations, cases of under-appreciated soft tissue infections including MRSA and necrotizing fasciitis, poorly chosen or mis-managed medications, questionable documentation (usually related to an EHR), and poorly coordinated transfer of care or “handoffs.” Similar problems. Multiple cases. Some of these were plaintiff cases, some were defense. Some were settled, a few went to trial, and many were dismissed without ever becoming lawsuits.
I can understand the first case in a series, but I cannot accept the second, third or fourth. And while every single case has something to teach physicians – it’s not happening.
The work I have done as an expert in med mal cases has been the best possible education to make me a better and safer physician. And as I see the same mistakes being made over and over – almost always correctable mistakes in “critical thinking,” documentation, or communication – I realize how important it is that all physicians learn from the (usually) very human mistakes of our medical colleagues.
In a December 2014 report from the Harvard School of Public Health entitled “The Public’s Views on Medical Error in Massachusetts,” 90% of patients who reported a medical error did so “to keep this from happening to someone else.” Only 17% did so seeking compensation for the error.
But because med mal settlements are almost always confidential, physicians learn nothing, leaving the next physician/patient encounter of a similar nature no less risky than before. It’s as if the injuries to one patient, the stress of a malpractice suit on the caregivers and families, and the horrendous expense of litigation, settlement or verdicts, is irrelevant. I find this an injustice to the injured parties, whose primary goal of reporting an error has been subverted. If they only knew….
Beginning in 2015, I will be doing what I can to make that happen. To improve physician practices and enhance the safety of our patients, I am now publishing Medical Malpractice Insights – Learning from Lawsuits, an email newsletter for physicians.
The format of the publication will be short, easy to read summaries of med mal cases that busy docs can read on their smartphones. Each case will have a simple “Takeaway.” Cases will come from published sources or be anonymized when confidentiality is an issue. The goal is to improve patient safety and assure patients that what happened to them is being used to educate docs and keep the same mistake from being repeated. Examples of topics covered in early issues include missed dislocations, missed appendicitis, missed spinal epidural abscess, and failure to follow anti-coagulation protocols.
The publication is strictly opt-in and available only to healthcare providers.
If you would like more information on this project or would like to contribute a closed case with teaching points, please contact me.