Emergency medicine and medical indemnity: an insurer’s perspective

The media’s recent spotlight on wait times of emergency services across the nation have put the topic at the forefront of federal election talks. The timely conference; Emergency Department Management will showcase innovation and improvement strategies, for hospital management staff and allied health professionals. As we draw closer to the event, we were fortunate enough to talk with Day 2 speaker – Ursula Harrisson and her team at the Victorian Management & Insurance Authority about medical indemnity claims, emerging risks and innovations. She answered our questions below:

Medical indemnity claims arising from emergency medicine represents the second highest risk specialty. What’s the scale of claims that the VMIA addresses and how many of these adverse events are preventable?

Ursula: VMIA receives around 3500 reported adverse incidents each year, and of these around 500 become potential medical indemnity claims.

These claims vary from minor/ moderate injuries that are low in claim-value through to events involving permanent and severe disability, death and nervous shock. Emergency medicine claims are diverse by nature and include both low and high-value claims. An example of a high-value claim would be delayed diagnosis of bacterial meningitis. A low value claim may be an incident such as missed diagnosis of fracture or severed tendons.

The profile of emerging claims across the past five years indicates a reduction in the number of obstetrics claims; however emergency department claims are increasing. The reason for decreasing claims in obstetrics is associated in part with better risk management processes. The rise in emergency claims is associated with additional pressure on emergency departments, with the added complexity of short time frame turnaround targets.

Research suggests that most medical indemnity claims are preventable as they are linked to an adverse event in the patient care. An Australian study found that 16.6% patients suffered an adverse event of which 50% were preventable (Wilson et al 1995).

What are some of the major emerging risks in ED which contribute to patient harm?

Ursula: Analysis of claims data reveals the most common drivers of harm are diagnostic errors, inadequate handover, failure to adhere to clinical practice or hospital guidelines, lack of appropriate supervision of junior staff, missed results and medication errors.

Do administrators and clinicians have different risk profiles?

Ursula: In simple terms, it could be said that administrators and clinicians have different risk profiles based on the nature of their primary focus, with the Board or Executive managing operational and strategic risks and clinicians focused on the risk associated with the transactional service of delivering patient care.

What is perhaps less understood is the role that each group play in contributing to the management of risk across the organisation. For example, a failure to recognise and act on key strategic risks or poor managerial decisions can impact on systems, which in term contribute to patient harm.

From an operational and strategic perspective the most common problems faced by administrators is having a poor line of sight of the risks emerging in services and responding to these risks in a timely manner to mitigate wider risks to the organisation. In the literature, the failings at Mid-Staffordshire NHS Trust illustrate a good example of how administrators ignore patient safety at their own peril. The board and executive ignored the emergency department was a significant outlier for deaths and poor organisational culture, and also made resourcing decisions based on financial performance rather than operational need.

This resulted in a short-staffed and under resourced department, contributing to patient harm.

One strategy to overcome these potential issues is to adopt a united approach to risk management, where administrators and clinicians respond to common issues as a collective and establish strong communication channels to escalate risks.

Encouraging a transparent reporting culture where staff feel empowered to report risks or adverse events without the fear of blame can also support this strategy. Administrators and clinicians should understand that risk management is everyone’s responsibility rather than the responsibility of an individual or the few.

What are some of the innovations and patient safety strategies which could assist administrators and clinicians identify and work together to address these failings and improve patient safety in ED?

Ursula: There are many examples of innovations and strategies to assist both administrators and clinicians in reducing patient harm. VMIA has sponsored a number of projects to support health services address several factors contributing to adverse events.

A recent project in the emergency department focused on the discharge process, with a particular focus on reducing the incidence of re-admission. Other projects have included the implementation of the TeamSTEPPS program to address culture and a
n educational package to address the problem of cognitive bias in regards to diagnostic errors. Other more simple innovations include the implementation of ISBAR to improve clinical handover and EWS charts to recognise the deteriorating patient, which have now become common practice as examples of better practice.

At a systemic level, several emergency departments have looked at their environment and possible improvements to address patient flow problems. A number of Victorian hospitals have used LEAN methodology to assist ED departments to make improvements to layout in order to improve patient flow and reduce wastage in both equipment and time. Another initiative at a Victorian hospital has been to authorise emergency department physicians to admit patients to wards (instead of waiting for review from another speciality) and improving patient flow on the wards to reduce bed blocking.

In understanding risk management, what can Australian hospital systems learn from NHS?

Ursula: There were many learnings from the governance issues in the NHS such as Bristol Royal Infirmary, Mid-Staffordshire and Morecambe Bay that are transferable to an Australian setting.

When these cases occur, both locally and internationally, the common lessons are that hospitals need to have key functions in place to reduce patient harm and ensure good quality of care. These cases continue to highlight the importance of transparency, patient centred care, strong organisational culture and continuous improvement in clinical practice.

The NHS has also contributed to learning in the areas of patient flow and safety. For example, many busy NHS emergency departments have developed close working relationships with GPs to set up Urgent Care Centres. These centres assess and treat patients who would ordinarily see a GP, but have chosen to present to their emergency department.

Another initiative is the Schwartz rounds, a practice where staff can meet to discuss complex cases and reflect on the emotional aspects of their work. Clinical and non-clinical staff meet once per month in a facilitated environment, aiming to understand the challenges and rewards that are intrinsic to providing care to patients. The evidence suggest that staff who attend these rounds feel less stressed and isolated, gain increased insight and appreciate each other’s role within the organisation.  

How can a State Insurer such as VMIA support a health service or services around patient safety issues in emergency departments?

Ursula: VMIA supports and works with health services in three focus areas: prevention, recovery and assurance.

Assurance is provided through our close professional relationship with our government partners, where insights are shared to assist with closer monitoring of health services.

We provide support to health services to help them recover form claims and to look at the systems that may have contributed to the claims occurring.

VMIA also has a commitment to provide sponsorship and other support to projects that are sustainable and have the capacity to be rolled out on a state-wide basis. We host regular forums and workshops with clinicians and administrators to discuss risk insights and emerging risks in emergency departments. VMIA also plays an important role in training and building capacity in risk management across the sector, particularly focusing on boards and the executive.
Ursula will be joined by 21+ expert speakers at this year’s conference. For more details click here.