Using the scientific method to address non-clinical risk management issues concerning incident reports

“There are two ways to combat these fears,” said Timothy R. Bone, president of Florida-based MedMal Direct Insurance. “One, emphasize the importance that the incident report will not be placed in personnel records and that the only copy of the report goes directly to the risk manager. The risk manager can then work with legal counsel to fully protect this document … this advice has been standard for decades.

“Two, a new and very encouraging movement in advancing and protecting open communication between doctor and patient has been the implementation in many states of ‘apology statutes.’ These statutes allow full communications concerning an untoward medical incident without the fear of the discussions being used later as evidence in a court of law. The Sorry Works Coalition is advancing this type of reform with success, much to the dismay of the attorneys who represent patients against physicians. It’s simple human nature to want to discuss with somebody how an untoward medical incident occurred, and it’s much better for us all if that somebody is the attending physician and the hospital or clinic risk manager. If the doctor doesn’t openly communicate with their patient, then that patient will go to an attorney to ask for help in seeking answers. These ‘apology statutes’ have provided a secure avenue for physicians to clearly communicate with their patient, which has resulted in prompt resolution of most of these incidents.”

Both processes begin with the incident report.

“Incident reporting has three primary purposes—an early detection system of problems and compensable incidents; a foundation for an early investigation of all potentially serious incidents; and a database for long range problem detection, analysis and correction,” said Bone.

At issue is failure to notify the hospital or clinic risk manager in a timely manner regarding a potential negligence action. The solution lies in the manner and frequency in which incident reports are filed by physicians, nurses and other staff employees. This matter should be discussed by the hospital or clinic administration and the leadership of the medical staff.

“Policies and procedures to assure open communication between medical staff and their patients should be approved by the hospital administration and the leadership of the medical staff,” said Bone. “These policies and procedures should address the confidential nature of the incident report, emphasize that it will not be placed in personnel files nor will it be used as evidence in disciplinary proceedings. Also, no copies will be made of the reports nor will the reports be stored outside the risk manager’s office.”

Participation of all staff members in reporting incidents is crucial, Bone said.

“Even though obtaining staff commitment to participate in incident reporting is a difficult task, it’s mandatory to educate the staff as to the purposes of incident reporting,” he said. “When all staff, including physicians, view incident reporting as useful and supportive toward minimizing their medical malpractice liability exposure, they’ll be willing and dedicated participants in it.”

Even though there are many definitions of a reportable incident that applies to all healthcare provider settings, Bone’s favorite is from the Chicago Hospital Risk Pooling Program, originally written in 1982: “An occurrence is any event that happens in the hospital or on the hospital premises that is not consistent with routine patient care or with the routine operation of the facility and that adversely affects or threatens to affect the health, life, or comfort of a patient or visitor.”

Types of occurrences include a missed diagnosis or misdiagnosis that results in patient injury, surgically related occurrences such as operating on the wrong patient or performing the wrong procedure, treatment and procedure occurrences such as burns or reactions to contrast material, medication occurrences such as the wrong dosage, and falls.

“To note that incident reports cover subjects beyond the usual med-mal allegations, one of the largest verdicts in my long experience was the result of an incident where a teenage visitor to a teenage patient in a hospital kicked the patient’s crutch and caused the patient to fall,” Bone said.

The review procedure involves obtaining the cooperation of the hospital or clinic administrator to review the policies and procedures being implemented by the hospital to deal with “incident reports” prepared by hospital or clinic staff. If these policies and procedures fail to involve any of the issues outlined above, prepare a simple policy and procedure document that ameliorates those problems and have it reviewed and approved by the administration and the leadership of the medical staff, suggested Bone. 

“If all is in order, notify the Medical Executive Committee and the medical staff,” he said. “If problems exist, devise a solution, implement it, re-audit the issue within a given time frame and report to the Medical Executive Committee and the medical staff about both the activity and the outcome.” 

A meaningful incident reporting system that identifies and initiates responses to actual and potential patient injuries is the backbone of any effective risk management program, Bone emphasized. 

“Overcome the problems by having the executive team provide full commitment to the design and implementation of an incident reporting system that is in place throughout the hospital or clinic,” he said. “This commitment will enable the risk manager to educate the staff as to the purpose and value of incident reporting, allowing it to become a focused tool to facilitate the reduction of injury and the mitigation of malpractice liability.” 

Editor’s Note: This article marks the seventh in a risk management series with Timothy R. Bone, president of Florida-based MedMal Direct Insurance. Florida Medical News addresses some of the most common non-clinical problems by objectively approaching each issue and its resolution via the scientific method. This process includes providing an “outcome goal” or objective, and then offering a relatively simple approach to data-gathering via chart review, observations, or simple surveys.

The series flows from the following known fact: as much as 80 percent of all medical malpractice lawsuits are generated from non-clinical issues in the practice of medicine.

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