Malpractice risk in ambulatory settings: an increasing and underrecognized problem.
IF A GROUP OF PHYSICIANS WERE ASKED TO LIST THE SPEcialties of clinical medicine that carry the highest risk of malpractice, invariably the first responses would include obstetrics/gynecology, anesthesia, and various surgical specialties. These clinical domains are well recognized to carry risk and have done so for many years. The results of adverse events in these clinical fields tend to be catastrophic and historically have often resulted in highprofile legal cases, covered in the media and associated with large indemnity payments. It is the rare clinician who will list a general internist or other noninterventional outpatient specialty in the list of high-risk physicians. This unrecognized risk, and the associated absence of risk management programs in ambulatory care settings across the country, is a cause for concern. The article by Bishop and colleagues in this issue of JAMA highlights an increasing risk of malpractice in the ambulatory area and makes some tentative initial steps to identify its causes. In this way, the study is a wake-up call for physicians who practice primarily in ambulatory settings and for physicians and administrators with the ability to set policy for these areas. Bishop and colleagues used data from the National Practitioner Data Bank (NPDB), which inventories payments made on malpractice events nationally, either through settlement or trial resolution. The NPDB also tracks disciplinary actions made against physicians at the state level. Although 71% of the events from 2005 to 2009, the period of the study, included in the database were related to disciplinary actions, there were more than 10 000 malpractice payments registered each year, resulting in a large number for the analysis by Bishop et al. The authors found that in 2009, more than half of malpractice events occurred in the outpatient area. In addition, although the total number of claims gradually decreased during the 5-year study period, the rate of this decline was slower in the ambulatory setting and there was a small but statistically significant increase in the percentage of events occurring in outpatient areas. The NPDB has minimal data available regarding the details of these claims, and the authors report on 6 categories to classify cause: diagnostic, surgical, obstetric, treatment/medication, anesthesia, or other. Not surprisingly, Bishop et al found that treatment and diagnostic adverse events predominated in the outpatient area. The use of malpractice claims to evaluate risk and develop programs in patient safety is not without limitations. Malpractice claims represent a small fraction of total adverse events. Additionally, they generally represent a unique convergence of circumstances that invariably include communication, documentation, and interpersonal issues. Moreover, malpractice claims have a temporality to them and typically many years elapse between the assertion of a claim and its resolution. However, malpractice claims represent the tip of the iceberg for patient safety events. For every claim, there are likely many near-misses or events with less severe outcomes that can be related to process errors similar to those that resulted in the claim. Thus, understanding patterns of malpractice claims and related events can facilitate identification of high-risk areas and accelerate the development of programmatic interventions to improve patient safety and mitigate risk. The explanation for the observed increase in malpractice claims in outpatient areas is not entirely clear. On one level, it may simply be related to a shift of care delivery from inpatient to outpatient settings. Nationally, hospital systems are developing wide networks of community-based ambulatory practices with the goal of transferring more care to the outpatient area. This shift has resulted in complex patients with multiple comorbid illnesses being increasingly cared for in less structured environments, potentially increasing the risk of errors. Other contributing factors might include the fact that many internists today see more patients daily and have less time for each encounter. Additionally, the amount of data available for each patient and the coordination of care across multiple specialties increasingly makes the sheer volume of information overwhelming for the clinician. For instance, one study estimated that