Sharing the pain: lessons from missed opportunities for healthcare improvement from patient complaints and litigation in the Australian health system
Benjamin M. Nowotny A B E , Erwin Loh C , Katherine Lorenz C and Euan M. Wallace A B D
+ Author Affiliations
- Author Affiliations
A Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Vic. 3800, Australia. Email: euan.wallace@monash.edu
B The Ritchie Centre, Hudson Institute of Medical Research, 27–31 Wright Street, Clayton, Vic. 3168, Australia.
C Monash Health, Clayton, Vic. 3168, Australia. Email: erwin.loh@monashhealth.org; katherinelorenz@monashhealth.org
D Safer Care Victoria, Department of Health and Human Services, Victorian Government, Melbourne, Vic. 3000, Australia.
E Corresponding author. Email: benjamin.nowotny@monash.edu
Australian Health Review 43(4) 382-391 https://doi.org/10.1071/AH17266
Submitted: 22 November 2017 Accepted: 4 February 2018 Published: 19 June 2018
Journal Compilation © AHHA 2019 Open Access CC BY-NC-ND
Abstract
Learning from medical errors to prevent their recurrence is an important component of any healthcare system’s quality and safety improvement functions. Traditionally, this been achieved principally from review of adverse clinical outcomes. The opportunity to learn systematically and in a system manner from patient complaints and litigation has been less well harnessed. Herein we describe the pathways and processes for both patient complaints and medicolegal claims in Victoria, and Australia more broadly, and assess the potential for these to be used for system improvement. We conclude that both patient complaints and medicolegal claims could afford the potential to additionally inform and direct safety and quality improvement. At present neither patient complaints nor medicolegal claims are used systematically to improve patient safety. We identify how this may be done, particularly through sharing findings across agencies.
What is known about the topic? Patient complaints and medicolegal claims are accepted parts of the healthcare industry. However, using these in a shared and collated manner as part of an improvement agenda has not been widely considered or proposed.
What does the paper add? This paper provides a summary of the patient complaint and medicolegal landscape in public hospital system in Australia broadly, and Victoria more specifically, identifying the agencies involved and the opportunities for sharing learnings. The paper draws on existing literature and experiences from both Australia and elsewhere to propose a framework whereby complaints and claims data could be shared systematically and strategically to reduce future harm and improve patient care.
What are the implications for practitioners? We offer an approach for practitioners, healthcare managers and policy makers in all Australian jurisdictions to design and implement a statewide capacity to share patient complaints and medicolegal claims as an additional component of system quality and safety.
References
[1] Elwyn G, Corrigan JM. The patient safety story. BMJ 2005; 331 302–4.| The patient safety story.Crossref | GoogleScholarGoogle Scholar |
[2] Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard medical practice study I. N Engl J Med 1991; 324 370–6.
| Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard medical practice study I.Crossref | GoogleScholarGoogle Scholar |
[3] Australian Institute of Health and Welfare (AIHW). Admitted patient care 2014–15. Australian hospital statistics. Canberra: AIHW; 2016.
[4] Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ (Online) 2016; 353 i2319
[5] Australian Council for Safety and Quality in Health Care (ACSQHC). Lessons from the inquiry into obstetrics and gynaecological services at King Edward Memorial Hospital 1990–2000. Sydney: ACSQHC; 2002.
[6] Davies G. Queensland public hospitals commission of inquiry. Brisbane: The Health Quality and Complaints Commission (Queensland); 2005.
[7] Morris A, Edwards L, Vider M, Andrews D, Morzone E, Atkinson D, Groth D. Interim report of 10 June, 2005. Brisbane: Bundaberg Hospital Commission of Inquiry; 2005.
[8] Duckett S, Cuddihy M, Newnham H. Targeting zero: supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care. Report of the Review of Hospital Safety and Quality Assurance in Victoria. Melbourne: State Government of Victoria Department of Health and Human Services; 2016.
[9] Picone D, Pehm K. Review of the Department of Health and Human Services’ management of a critical issue at Djerriwarrh Health Services. Melbourne: Australian Commission on Safety and Quality in Health Care; 2015.
[10] Chant K. Bankstown–Lidcombe Hospital medical gasses incident: final report. Sydney: State Government of New South Wales Department of Health; 2016.
[11] Groves A, Thomson D, McKellar D, Procter N. The Oakden report. Adelaide: State Government of South Australia Department for Health and Ageing; 2017.
[12] Kennedy I. The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995. London: The Bristol Royal Infirmary Inquiry; 2001.
[13] Francis R. Report of the Mid Staffordshire NHS Foundation Trust public inquiry. London: The Mid Staffordshire NHS Foundation Trust Public Inquiry; 2013.
[14] Kirkup B. The report of the Morecambe Bay investigation. London: The Stationery Office; 2015.
[15] Bismark MM, Spittal MJ, Gurrin LC, Ward M, Studdert DM. Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia. BMJ Qual Saf 2013; 22 532–40.
| Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia.Crossref | GoogleScholarGoogle Scholar |
[16] Bismark MM, Spittal MJ, Studdert DM. Prevalence and characteristics of complaint-prone doctors in private practice in Victoria. MJA 2011; 195 25–8.
[17] Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med 2011; 365 629–36.
| Malpractice risk according to physician specialty.Crossref | GoogleScholarGoogle Scholar |
[18] Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA 2002; 287 2951–7.
| Patient complaints and malpractice risk.Crossref | GoogleScholarGoogle Scholar |
[19] Kellogg KM, Hettinger Z, Shah M, Wears RL, Sellers CR, Squires M, Fairbanks R. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Qual Saf 2017; 5 381–7.
[20] Macrae C. Early warnings, weak signals and learning from healthcare disasters. BMJ Qual Saf 2014; 23 440–5.
| Early warnings, weak signals and learning from healthcare disasters.Crossref | GoogleScholarGoogle Scholar |
[21] Keogh B. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. London: National Health Service (UK); 2013.
[22] Department of Health. Victorian health incident management policy guide. 2011 Available at: http://www.health.vic.gov.au/clinrisk/vhims/ [verified 30 May 2018].
[23] Riskman. Modules. 2012. Available at: http://www.riskman.net.au [verified 30 May 2018].
[24] Queensland Department of Health Patient Safety and Quality Improvement Service. Hospital and health service – consumer feedback report. Brisbane: Queensland Government; 2017.
[25] Reader TW, Gillespie A, Roberts J. Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf 2014; 23 678–89.
| Patient complaints in healthcare systems: a systematic review and coding taxonomy.Crossref | GoogleScholarGoogle Scholar |
[26] Harrison R, Walton M, Healy J, Smith-Merry J, Hobbs C. Patient complaints about hospital services: applying a complaint taxonomy to analyse and respond to complaints. Int J Qual Health Care 2016; 28 240–5.
| Patient complaints about hospital services: applying a complaint taxonomy to analyse and respond to complaints.Crossref | GoogleScholarGoogle Scholar |
[27] Health and Disability Services Complaints Office (WA). 2015–16 Annual report. Perth: Government of Western Australia Department of Health; 2016.
[28] Office of the Health Services Commissioner (Victoria). 2016 Annual report. Melbourne: Victorian Government Department of Health; 2016.
[29] Bixenstine PJ, Shore AD, Mehtsun WT, Ibrahim AM, Freischlag JA, Makary MA. Catastrophic medical malpractice payouts in the United States. J Healthc Qual 2014; 36 43–53.
| Catastrophic medical malpractice payouts in the United States.Crossref | GoogleScholarGoogle Scholar |
[30] Rolph JE, Adams JL, McGuigan KA. Identifying malpractice-prone physicians. J Empir Leg Stud 2007; 4 125–53.
| Identifying malpractice-prone physicians.Crossref | GoogleScholarGoogle Scholar |
[31] Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med 2004; 350 283–92.
| Medical malpractice.Crossref | GoogleScholarGoogle Scholar |
[32] Pichert J, Hickson G, Moore I. Using patient complaints to promote patient safety. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: new directions and alternative approaches. Volume 2: culture and redesign. Rockville: Agency for Healthcare Research and Quality; 2008. Available at: https://www.ncbi.nlm.nih.gov/books/NBK43703/ [verified 30 May 2018].
[33] Moore IN, Pichert JW, Hickson GB, Federspiel C, Blackford JU. Rethinking peer review: detecting and addressing medical malpractice claims risk. Vand L Rev. 2006; 59 1175–206.
[34] Hickson GB, Federspiel CF, Blackford J, Pichert JW, Gaska W, Merrigan MW, Miller CS.. Patient complaints and malpractice risk in a regional healthcare center. South Med J 2007; 100 791–6.
| Patient complaints and malpractice risk in a regional healthcare center.Crossref | GoogleScholarGoogle Scholar |
[35] The Australian Government Department of Health. National registration and accreditation scheme (NRAS). 2016. Available at: http://www.health.gov.au/internet/main/publishing.nsf/content/work-nras [verified 30 May 2018].
[36] Australian Health Practitioner Regulation Agency. What we do. 2017 Available at: http://www.ahpra.gov.au/About-AHPRA/What-We-Do.aspx [verified 30 May 2018].
[37] Australian Health Practitioner Regulation Agency. About. 2015 Available at: http://www.ahpra.gov.au/About-AHPRA.aspx [verified 30 May 2018].
[38] Medical Board of Australia. About. 2015 Available at: http://www.medicalboard.gov.au/About.aspx [verified 30 May 2018].
[39] Closure of the physician assistant program at The University of Queensland.’ Health report. Radio National, ABC, 23 May 2011. Available at: http://www.abc.net.au/radionational/programs/healthreport/closure-of-the-physician-assistant-program-at-the/2950238 [verified 9 April 2018].
[40] McKenzie N, Baker R. Alleged sex abuse doctor Andrew Churchyard allowed to keep working by Cabrini hospital. The Sydney Morning Herald 2 August 2016.
[41] McGhee A. Medical regulator accused of failing to act on complaints. ABC; 2017.
[42] McGhee A. Medical regulator promises changes after infant deaths and sexual abuse by doctor. ABC News. ABC News 4 August 2017.
[43] Statement from the Medical Board of Australia and AHPRA [press release]. Australian Health Practitioner Regulation Agency, 2 August 2016. Available at: http://www.medicalboard.gov.au/News/2016-08-02-statement.aspx [verified 30 May 2018].
[44] Australian Health Practitioner Regulation Agency. Privacy. 2015 Available at: http://www.ahpra.gov.au/about-ahpra/privacy.aspx [verified 30 May 2018].
[45] Runciman WB, Williamson JAH, Deakin A, Benveniste KA, Bannon K, Hibbert PD. An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Qual Saf Health Care 2006; 15 i82–90.
| An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification.Crossref | GoogleScholarGoogle Scholar |
[46] Vukmir RB. Medical malpractice: managing the risk. Med Law 2004; 23 495–513.
[47] Cohen D, Chan SB, Dorfman M. Malpractice claims on emergency physicians: time and money. J Emerg Med 2012; 42 22–7.
| Malpractice claims on emergency physicians: time and money.Crossref | GoogleScholarGoogle Scholar |
[48] The County Court of Victoria. Medical list. 2016. Available at: http://www.countycourt.vic.gov.au/medical-list [verified 30 May 2018].
[49] The Supreme Court of Victoria. Common law division. 2016. Available at: https://www.supremecourt.vic.gov.au/law-and-practice/areas-of-the-court/common-law-division [verified 30 May 2018].
[50] Furrow BR
[51] Marchev M. Medical malpractice and medical error disclosure: balancing facts and fears. Portland: National Academy for State Health Policy; 2003.Available at: https://nashp.org/wp-content/uploads/sites/default/files/balancing_facts_fears.pdf [Verified 30 May 2018]
[52] Kesselheim AS, November MT, Lifford KL, McElrath TF, Puopolo AL, Orav EJ. Using malpractice claims to identify risk factors for neurological impairment among infants following non-reassuring fetal heart rate patterns during labour. J Eval Clin Pract 2010; 16 476–83.
[53] Department of Anesthesiology and Pain Medicine. Anesthesia closed claims project. University of Washington; 2017. Available at: https://depts.washington.edu/asaccp/projects/anesthesia-closed-claims-project [verified 30 May 2018].
[54] Sloan F, Chepke L. From medical malpractice to quality assurance. Issues Sci Technol 2008; 24 63–70.
[55] Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Kachalia A, Yoon C, Puopolo AL, Brennan TA. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med 2006; 354 2024–33.
| Claims, errors, and compensation payments in medical malpractice litigation.Crossref | GoogleScholarGoogle Scholar |
[56] Victorian Managed Insurance Authority (VMIA). Victorian Managed Insurance Agency annual report. Melbourne: VMIA; 2016.
[57] National Health Service Litigation Authority (NHSLA). Ten years of maternity claims. An analysis of NHS litigation authority data. London: NHSLA; 2012.
[58] National Health Service Litigation Authority (NHSLA). Study of stillbirth claims. London: NHSLA; 2009.
[59] National Health Service Litigation Authority (NHSLA). Claims related to medical devices and equipment. London: NHSLA; 2010.
[60] Victorian Managed Insurance Authority (VMIA). Identifying emerging medical indemnity risk in Victoria (VMIA occasional paper). Melbourne: VMIA; 2013.
[61] Frost P. Patient safety in Victorian public hospitals. Melbourne: Office of the Victorian Auditor General; 2016.
[62] Grey E, Kennedy I. The report of the independent review of children’s cardiac services in Bristol. Bristol: University Hospitals Bristol; 2016.
[63] Walker B. Interim report of the special commission of inquiry into Campbelltown and Camden Hospitals. Sydney: State Government of New South Wales; 2004.
[64] Walker B. Second interim report of the special commission of inquiry into Campbelltown and Camden Hospitals. Sydney: State Government of New South Wales; 2004.
[65] The Coroners Court of Victoria. Information for health professionals. 2011. Available at: http://www.coronerscourt.vic.gov.au/resources/af021994-c0cc-4b39-95a0-49dcf08f812b/info_health_pros+4pp+a4+2013+lr.pdf [verified 30 May 2018].
[66] The Coroners Court of Victoria. About us. 2016. Available at: http://www.coronerscourt.vic.gov.au/home/about+us/ [verified 30 May 2018].
[67] Victoria State Government. Consultative Council on Obstetric and Paediatric Mortality and Morbidity. 2015 Available at: https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/consultative-councils/council-obstetric-paediatric-mortality [verified 30 May 2018].
[68] Royal Australasian College of Surgeons. Victorian audit of surgical mortality. 2017 Available at: http://www.surgeons.org/for-health-professionals/audits-and-surgical-research/anzasm/vasm/ [verified 30 May 2018].
[69] Anderson A. Ten years of maternity claims: an analysis of the NHS Litigation Authority data – key findings. Clin Risk 2013; 19 24–31.
| Ten years of maternity claims: an analysis of the NHS Litigation Authority data – key findings.Crossref | GoogleScholarGoogle Scholar |
[70] Australian Commission on Safety and Quality in Health Care (ACQSHC). The second Australian atlas of healthcare variation. ACQSHC. 2017. Available at: http://acsqhc.maps.arcgis.com/apps/MapAndAppGallery/index.html?appid=fd3b04ebe3934733b7ecb8514166c08f [verified 29 May 2018].
[71] Australian Institute of Health and Welfare (AIHW). Australia’s mothers and babies 2015 – in brief. Perinatal Statistics Series no. 33. Catalogue no. PER 91. Canberra: AIHW; 2017.
[72] Centre for Epidemiology and Evidence. New South Wales mothers and babies 2015. Sydney: NSW Ministry of Health; 2016.
[73] Maternal and Child Health Unit. Western Australia’s mothers and babies, 2013: 31st annual report of the Western Australian Midwives’ Notification System. Perth: Department of Health; 2016. Available at: https://ww2.health.wa.gov.au/~/media/Files/Corporate/Reports%20and%20publications/Perinatal%20infant%20and%20maternal/WA_Mothers_Babies_2013.pdf [verified 30 May 2018].
[74] Maternal and Perinatal Mortality Committee. Maternal and perinatal mortality in South Australia 2015. Adelaide: SA Health; 2017.
[75] Safer Care Victoria. Victorian perinatal services performance indicators 2015–2016. Melbourne: Department of Health and Human Services; 2017.
[76] Scheil WJK, Scott J, Catcheside B, Sage L, Kennare R. Pregnancy outcome in South Australia 2015. Adelaide: Pregnancy Outcome Unit, SA Health; 2017.
[77] Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, Brennan TA. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 2005; 293 2609–17.
| Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.Crossref | GoogleScholarGoogle Scholar |
[78] Nash LM, Kelly PJ, Daly MG, Walter G, van Ekert EH, Walton M, Willcock SM, Tennant CC. Australian doctors’ involvement in medicolegal matters: a cross-sectional self-report study. Med J Aust 2009; 191 436–40.
[79] Nowotny B, Loh E, Wallace EM. Patient factors as a predictor of medicolegal risk in obstetrics: a new quality improvement opportunity. J Paediatr Child Health 2017; 53 73
| Patient factors as a predictor of medicolegal risk in obstetrics: a new quality improvement opportunity.Crossref | GoogleScholarGoogle Scholar |
