Report: After 20 Years, Why Isn’t Patient Safety Better?

By John Palmer

It’s been 21 years since the Institute of Medicine released its landmark patient safety report To Err Is Human. A new report from medical liability insurer Coverys takes a close look at why patient safety in this country is still far from optimal.

The report examined 20,211 closed medical malpractice claims from 2010 to 2019 to provide risk managers, clinicians, and healthcare executives a unique view into factors that lead to claims. It is intended as a tool to proactively reduce conditions that result in patient harm and financial risk.

As a conversation starter, the report seeks to create a foundation for a national-level examination into risk management issues and causation factors.

“Despite concerted efforts to improve patient safety over the past 20 years, patients continue to experience high-severity injury outcomes,” wrote lead author Ann Burke, RN, CPHRM, CPPS, senior director of risk management for Coverys before her recent retirement. “This report explores how efforts in the decade following the 10-year anniversary of To Err Is Human have not delivered optimal results. It raises vital questions and renewed areas of focus.”

The October report, titled A Call for Action: Insights From a Decade of Malpractice Claims, was written by Burke, as well as Robert Hanscom, JD, vice president of risk management and analytics; Ann Lambrecht, RN, BSN, JD, FASHRM, senior risk specialist; Amit Patel, MBA, director of advanced analytics and innovation; and Maryann Small, MBA, senior director of risk analytics.

The report is the sixth in Coverys’ “Dose of Insight” series, which explores the increased risk and liability brought on by several patient safety issues in healthcare, and offers suggestions on how to improve. Previous reports have studied medication errors, errors in the emergency department (ED), diagnostic accuracy, surgical malpractice claims, and obstetrics.

Some of the major findings of the latest report include the following:

  • Clinicians and organizations are seeing increasingly high financial payouts for malpractice claims. In 2010, the average indemnity paid was $342,581; by 2019 it was $411,053.
  • The overall number of claims reported is trending downward, but both average indemnity and expenses are trending upward.
  • Surgery/procedure-related allegations were the most frequent, followed closely by diagnosis-related allegations—combined, they accounted for 57% of allegations and 59% of indemnity paid.

“Surgical care is inherently risky, and when things go wrong, is a common basis for malpractice claims,” the report concluded. “Despite widely distributed guidance, checklists, team training, and simulation aimed at reducing their prevalence, events continue to occur involving retained foreign bodies, wrong site procedures, and less-than-optimal team performance.”

  • Sixty-three percent of claims involved a surgeon with multiple claims.
  • Persistent risks that lead to poor patient outcomes involve the interweaving of communication, process, and cognitive issues.
  • Retained foreign bodies, wrong-site procedures, and less-than-optimal team performance are still some of the most prevalent surgical complications.
  • In some better news, anesthesia-related claims have decreased by more than half, attributed somewhat to the fact that anesthesia is now highly data-driven with a focus on simulation training, human factors engineering, and evidence-based decision-making.

A long way to go

The underlying message of the Coverys report seems to be that there is still a lot of work to do in improving patient safety.

“Healthcare seems to push back on the notion of standardization, yet variability is what we frequently see populating a large number of malpractice cases,” says co-author Hanscom. “Most other industries, in their drive to become safer and more reliable, have focused hard on eliminating unnecessary variability.”

According to Hanscom, the industry’s refusal to change archaic practices that lead to mistakes has helped keep the past decade slow in terms of patient safety improvements.

Checklists and other standard protocols have led to safety advancements in other industries, such as aviation, and Hanscom says the secret to safety lies in the removal of variables in several areas, such as the following:

  • Technical performance. Organizations that have invested in surgical simulation capabilities (i.e., skills labs) are actively focusing on ways for surgeons to learn, practice, and sharpen their skills in a simulated environment. Also, hospitals need to cut down on noise and distractions in the OR.
  • Cognitive skill. Variability in cognitive skill is at the root of many missed diagnosis cases. Clinicians can get caught in a narrow diagnostic focus, perhaps inadvertently influenced by their own cognitive biases.

“We know that many organizations have invested in resources that provide decision support—and that emphasis should continue,” Hanscom says. “But perhaps this is an area of future innovation. Can we create cognitive simulation tools and ways by which clinicians can actively practice their diagnostic skills, even understand where they might succumb to moving too fast or jumping to a likely conclusion?”

  • Different healthcare specialties have different processes, and there is very little standardization in key areas. An integral component of high-reliability environments is having well-defined underlying systems to support patient care. These environments have processes that are well thought out and universally understood, leaving minimal room for care to fall through the cracks.
  • Communication breakdowns occur between providers when patients are transitioning from one critical domain to another—for instance, moving from the OR to recovery or the ICU, or from the ED to an inpatient bed.

As for emerging risks, the report singled out several areas that need to be watched, including new technology, novel procedures, and current events like the coronavirus pandemic. In addition, the growing use of urgent care and walk-in clinics, electronic health records, telehealth, and robotics could all be ripe for future diagnostic and communication errors, the report pointed out.

Some better news

The report identified some areas where there seems to be a declining trend in claims against some practices, such as radiology, anesthesiology, and emergency medicine.

The overall claims rate for anesthesiology was reduced by more than 50% over the 10 years of claims analyzed, which may be attributed to the use of data to drive practice improvements.

“It comes back to the old adage that you can’t manage what you can’t measure,” says report co-author Lambrecht. “When there is baseline data from which to work that identifies when in the anesthesia process the event occurred and calls out the type and severity of the injury, it becomes easier to identify the root cause or causes that contributed to the outcome. These data also tell us which interventions have the greatest likelihood to produce better outcomes.”

She adds that while the claims rate is declining in the ED, there is almost no change in claims over a 10-year period, and there is room for improvement given the significant advancements in technology and enhanced decision support tools.

“Factored into clinical judgment are patient assessment and diagnosis, selection and management of therapy, and a failure or delay in obtaining a consultation or referral,” she says. “These can be improved through using clinical decision support tools and having consultation policies that require a specialist referral and can reduce or eliminate the probability of a narrow diagnostic focus or implicit yet unconscious bias. With these aspects addressed, it may lead to more effective selection of treatment and management of therapy.”

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at